Merrow Park Surgery

We carried out an announced focused inspection at Merrow Park Surgery on 14 June 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 24 November 2021, the practice was rated requires improvement overall and for providing safe and well led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Merrow Park Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulations 12 Safe care and treatment, 17 Good governance and 19 Fit and proper persons employed from our previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

At our last inspection the practice was rated as requires improvement because:

• Staff vaccination was not maintained in line with current Public Health England (PHE) guidance relevant to their role.
• The practice had not fully implemented it’s policy for reporting and recording significant events. There was limited evidence to show that lessons learnt had been identified and shared.
• Recruitment checks were not always carried out in line with regulations.
• Not all staff had the appropriate authorisations to administer medicines under patient group directions.
• Systems for assessing, monitoring and improving the quality and safety of the service were not always effective.
• Leaders lacked oversight of some processes and therefore failed to identify risks when those processes did not operate as intended.
• The practice did not always act on appropriate and accurate information.

At this inspection we found that:

• The practice required all staff members to provide evidence of their immunisation status. This was recorded into a spreadsheet. Risk assessments had been completed for those staff members whose immunisation was not known or had declined the immunisation.
• The recording of significant events, complaints and safety alerts was clear and detailed. We saw minutes to meetings where these were discussed for wider learning.
• The staff recruitment files we reviewed contained all of the required information.
• Staff had appropriate authorisations to administer medicines under patient group directions.
• Systems were in place to monitor training and infection control audits and action plans.
• Systems for assessing, monitoring and improving the quality and safety of the services were effective.
• Leaders had oversight of the processes and procedures operating in the practice and were assured that these were operating as intended.
• The practice was acting on appropriate and accurate information.
• There was effective and open communication and information sharing amongst the staff team. There were regular management, clinical and team meetings and staff felt motivated to contribute to driving improvement within the practice.
• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• There were adequate systems to assess, monitor and manage risks to patient safety.
• The practice had systems for the appropriate and safe use of medicines, including medicines optimisation and high risk medicines.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There were evidence of systems and processes for learning and continuous improvement.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

We saw the following outstanding practice:

Leaders in the practice had focused on staff well-being and introduced a number of new initiatives. For example, a well being day where staff received a day off without having to use annual leave if their birthday fell on a working day. Personalised birthday cards from the partners and a shout out board where compliments about the surgery and individuals were displayed for all staff to see.The practice had rewritten their vision and values with involvement from all leaders and staff. The practice had run a competition amongst the staff and leaders to design a new logo for the practice. Staff we spoke with told us this had a notable impact on staff well-being and morale in the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care