St Mary Street Surgery - Care Quality Commission

Background to this inspection

Updated 27 July 2017

St Mary Street Surgery operates from one location, which is:

The Surgery, St Mary Street, Thornbury, South Gloucestershire, BS35 2AT

The practice is based within Thornbury town centre and provides primary care services to patients from within the Thornbury area including Alveston and the villages of Oldbury-on-Severn, Olveston, Tockington and Tytherington.
The practice premises were purpose built. They also rented additional space from the building next door and provide minor surgery clinics in the local community hospital.
Patient services are located on the ground and first floor of the building. The first floor can be accessed by stairs. Patients unable to access the first floor were seen by clinical staff on the ground floor.
There is no patient parking but there are direct bus routes close to the practice and a short stay car park opposite the practice.
The practice is open from Monday to Friday 8am-6:30pm. Extended opening hours were available on Monday evening from 6:30pm and Thursday mornings from 7:20am.
When the practice is not open patients can access the NHS 111 service for advice and if necessary referred to Brisdoc GP out of hours services.
The practice has a population of approximately 7100 patients.

The practice has a Personal Medical Services contract (PMS) with NHS England to deliver general medical services. In addition to this contract the practice had enhanced services which included facilitating timely diagnosis for patients with dementia and childhood immunisations.

The practice has the following staffing:

Four GP partners (two male and two female); working to the equivalent to 3.1 whole time equivalent GPs.
A nurse prescriber, two practice nurses, a health care assistant and a phlebotomist (all female) working to the equivalent of 3.3 whole time equivalent nursing staff.
An operations practice manager and a strategic practice manager.
A senior receptionist and six receptionists and four administrators.
St Mary Street Surgery is a GP teaching practice; there are four GP trainers and one GP registrar.

Overall inspection

Good

Updated 27 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of St Mary Street Surgery on 24 May 2016. The overall rating for the practice was requires improvement, with the safe and well-led domains rated as requiring improvement. The provider had resolved some of the concerns for the safe and well-led domains at our focused follow-up inspection on 28 February 2017. However, the provider had not rectified all the issues found previously in our comprehensive inspection and the practice remained as requiring improvement for providing safe and well-led services. Following the focused follow-up inspection we again issued two requirement notices. A notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment; and a notice was issued due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to good governance.

Within our last inspection report we reported that the provider must:

Ensure that confidential records, including patient medical records, were held securely at all times and within appropriate containers to remove the risk of damage and destruction.
Ensure that all actions from the fire risk assessment had been completed including the electrical installation safety check, to ensure staff were appropriately trained in fire safety including key members of staff who led the team and patients to safety.

In addition, the provider should:

Ensure blank prescription paper and pads were kept secure at all times.
Ensure formal risk assessments took place when staff were employed before all appropriate checks had been received.
Ensure actions, as identified from the practice legionella risk assessment were carried out.
Improve its systems on how it monitored the quality of care and treatment provided to its patients, and ensure that when auditing took place this was discussed with all of the clinical team to share learning.

We found the practice needed to improve its systems on how it monitored the quality of the care and treatment provided to its patients. For example, minor surgery results were not monitored for complications or for diagnostic accuracy.

The comprehensive and focused follow-up inspection reports can be found by selecting the ‘all reports’ link for St Mary Street Surgery on our website at www.cqc.org.uk.

We undertook a subsequent focused follow-up inspection of the practice on 3 July 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

There were key findings across all the areas we inspected during this follow-up inspection. We saw documentary and other evidence that:

The practice had assigned a dedicated room for medical records storage. The records were held in appropriate containers and the room had a lockable door that could only be accessed with a key, which was accessible by certain staff. In addition, we saw that blank prescription paper and pads were kept secure at all times behind locked doors that were only accessible to authorised staff.

All actions from the fire risk assessment had been completed, including an electrical installation safety check. Fire warden training had been completed by key members of staff responsible for team and patient safety.

In addition, we saw documentary and other evidence that:

The practice had a formal risk assessment in place if non-clinical staff were employed before all appropriate checks had been received.
Actions identified from the practice legionella risk assessment had been carried out. These included a record of weekly water system flushing.
Clinical audits had been completed and findings discussed with all the clinical team to share learning.

Following this inspection the practice was rated as good across all domains.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice