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Inspection Summary

Overall summary & rating


Updated 18 September 2018

We carried out an announced comprehensive inspection at Queen Mary Practice on 16 May 2017. The overall rating for the practice was overall Good, with the exception of key question ‘safe’ which was rated as requires improvement. The full comprehensive report on the May 2017 inspection can be found by selecting the ‘all reports’ link for Queen Mary Practice on our website at

This inspection was a focused inspection carried out on 27 July 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated as Good.

Our key findings were as follows:

  • Systems and processes designed to minimise risks to patients were effective. The practice had streamlined safeguarding policies which contained information about who to escalate safeguarding concerns to internally and externally.
  • There was a revised system for reviewing uncollected prescriptions held at the practice.
  • The practice regularly reviewed their performance in terms of providing good clinical outcomes for patients.
  • Complaints at the practice were handled in accordance to recognised guidance.
  • The practice had identified 62 patients as carers, which is over 1% of the practice list size.
  • The practice had reviewed its infection control policy and conducted a comprehensive internal infection control inspection. However, the last audit had taken place more than three months ago, which contradicts the practice infection control policy which states the inspections should be conducted quarterly.
  • There was evidence that a recent Legionella risk assessment had been conducted.

There were also areas of practice where the provider should make improvements.

The provider should:

  • Review the Infection Prevention and Control Policy in place at the practice to ensure that internal infection control inspections are conducted according to the schedule specified.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas



Updated 18 September 2018

At our previous inspection on 16 May 2017, we rated the practice as requires improvement for providing safe services as the arrangements in respect of effective systems to ensure at risk individuals were safeguarded from abuse and systems for reviewing uncollected prescriptions were not adequate.

These arrangements had significantly improved when we undertook a follow up inspection on 27 July 2018. The practice is now rated as good for providing safe services.

Safety systems and processes

There were processes for handling repeat prescriptions which included the review of high risk medicines. The practice had an effective system in place for monitoring uncollected prescriptions. The provider told us that uncollected prescriptions were now reviewed every two weeks by reception staff and any prescription that had not been collected two weeks after the date of issue was passed to the prescribing doctor or duty doctor for review. The practice would attempt contact with the patient to ascertain why they had not collected the prescription and this contact is documented with the patient’s clinical record. Dependant on the outcome of the conversation, the prescription could be held for a further limited period of time for collection. In the event of the practice not being able to make contact with a patient after two attempts (once by telephone and the second by text), the prescribing doctor or duty doctor is informed before the prescription is disposed of and this is action noted on the patient clinical record.

The practice had arrangements in place for safeguarding. The practice had a list on the clinical

system containing the names of patients where safeguarding concerns had been raised and following our last inspection in May 2017, alerts had now been alert placed on individual patient records which flagged safeguarding concerns to those clinicians accessing patient records.

There was a lead member of staff for safeguarding and all the staff we spoke with were aware of the identity of this staff member.








Checks on specific services

People with long term conditions


Updated 18 July 2017

The practice is rated as good for the care of patients with long term conditions.

  • The practice nurse and GPs both supported patients with long-term disease management and patients at risk of hospital admission were identified as a priority.

  • Performance for diabetes was comparable to local and national average achievement. For example

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs. Staff at the practice could email secondary care services for advice regarding the management of long term conditions.

  • There were processes in place for patients with long-term conditions who experienced a sudden deterioration in health.

  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people


Updated 18 July 2017

The practice is rated as good for the care of families, children and young people.

  • From the sample of documented examples we reviewed we found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. However these systems were not always effective; for instance there were several versions of the child safeguarding policy available which contained different information and though the practice had a list of vulnerable children; there was no alert in place on individual notes.

  • Pregnant women with a history of mental health problems were referred to local mental health services.

  • The practice had developed an ante natal pack which contained information for expectant mothers on local services available as well as information and advice on the stages of pregnancy and suggested supplements which would support a healthy pregnancy.

  • The practice would offer longer appointments for first time mothers.

  • The practice healthcare assistant offered a walk in flu clinic specifically for pregnant women.

  • Immunisation rates were relatively high for all standard childhood immunisations.

  • Staff told us, on the day of inspection, that children and young people would be treated in an age-appropriate way and recognised as individuals.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice worked with midwives and health visitors to support this population group. The health centre had a health visitor who attended on Tuesdays and undertook clinics for breast feeding as well as ante-natal, post-natal and child health surveillance. The health centre also had midwives who worked on site.

  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications. Children under five years old and pregnant women were seen as a priority.

Older people


Updated 18 July 2017

The practice is rated as good for the care of older people.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population. All patients over the age of 75 were reviewed and had care plans as part of a local enhanced service which had enabled the practice to identify those with undiagnosed conditions including dementia. Though this enhanced service had ceased the practice planning to continue these for certain categories of patients within this demographic including those who were frail or possible at risk of falling.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

  • Older patients who were housebound were reviewed annually and offered a flu immunisation. The practice aimed to provide more regular reviews for these patients. The practice nurse would undertake ear syringing for housebound patients.

  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

  • The practice called all older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

  • Where older patients had complex needs, the practice shared summary care records with local care services. The practice would utilise and refer patients to relevant support services including the fall clinic and phlebotomy service; though patients who were unable to attend this service were able to have blood taken from the practice’s healthcare assistant.

  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

  • The practice provided support to two independent living facilities and one nursing home. We contacted the manager of the nursing home and one of the independent living facilities to obtain feedback about the quality of care provided and were informed that the practice provided a high standard of care, were responsive when asked to attend the sites and went out of their way to ensure that residents’ health needs were promptly attended to.

Working age people (including those recently retired and students)


Updated 18 July 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours and Saturday appointments through the federation hub.

  • Text message health promotion was targeted as this population group.

  • The practice offered telephone consultations; trying to offer these at patient’s preferred times. The practice offered extended hours access for telephone consultations on Monday evenings from 6.30 pm to 7.30 pm. Half of all appointments were able to be booked online.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)


Updated 18 July 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia)


  • The practice carried out advance care planning for patients living with dementia.
  • 85% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average.
  • The practice did not have adequate systems in place for monitoring repeat prescribing for patients receiving medicines for mental health needs. Staff at the practice told us that they would only check uncollected prescriptions on an ad hoc basis; approximately every three months.
  • Performance in respect of other mental health indicators was comparable to the national average. However the percentage of patients exception reported who were aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who had been reviewed not earlier than 10 days after and not later than 56 days after the date of diagnosis was 43% compared with 22% in the CCG and 21% nationally.
  • The practice provided priority appointments for those experiencing mental health and would call all those with mental health problems who failed to attend their appointments.
  • The practice hosted a counsellor on site once a week who offered their services both to patients at the surgery and those from other practices in the CCG.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment.
  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable


Updated 18 July 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, asylum seekers and those with a learning disability.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

  • The practice healthcare assistant ran a phlebotomy service for vulnerable patients.

  • The practice offered longer appointments for patients classified as vulnerable including those with learning disabilities.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.