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Steppingstones Medical Practice Good


Inspection carried out on 24 July 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Steppingstones Medical Practice on 12 February 2019 as part of our inspection programme. We rated the practice as Good overall, however we found a breach of regulation and rated Well-led as Requires Improvement. You can read the full report by selecting the ‘all reports’ link for Steppingstones Medical Practice on our website at: 

We are mindful of the impact of Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based review.

On 24 July we carried out a desk-based review to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach of regulation we identified at our previous inspection on 9 February 2019.

We found that improvements had been made and the provider was no longer in breach of the regulation and we have amended the rating for this practice accordingly. The practice is now rated as Good for the provision of well-led services. We previously rated the practice as Good for providing safe, effective, caring and responsive services.

During this desk-based review we looked at a range of documents submitted by the practice to demonstrate how they had met the requirement notice. The documents we looked at included those relating to:

  • A revised structured clinical audit programme.
  • Revised systems to identify and review vulnerable adults on their clinical system.
  • A revised formal system in place for risk assessments as part of health and safety monitoring.
  • A revised referral tracking system in place.

During this desk-based review we looked at the following question:

Are services well-led?

We found that this service was providing a well-led service in accordance with the relevant regulations.

  • The practice had a programme of clinical audit in place to monitor and improve quality.
  • The practice had an effective system to identify all known vulnerable adults and children on their clinical system.
  • Health and safety arrangements had been strengthened and risk assessments put in place as part of risk management.
  • The referral tracking system had been reviewed and a system in place to manage this proactively.
  • The practice were continuing to engage with the patient participation group who had supported the practice with a number of campaigns.

The areas where the provider should make improvements are:

• Further explore ways to increase the uptake rates for cervical cancer screening.

• Explore ways to increase the identity of patients who also act as carers.

• Continue to review the patient satisfaction rates with telephone access.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 12 February 2019

During a routine inspection

Inspection carried out on 28 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Steppingstones Medical Practice on 28 October 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Risks to patients were assessed and well managed.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Results from the national GP patient survey published in July 2015 showed that patient’s responded positively regarding access to care and treatment. However, we received mixed feedback on the day of our inspection as some patients highlighted that it was difficult to access the practice through telephone and that waiting times were sometimes long.

  • The practice had good facilities and was equipped to treat patients and meet their needs.

  • While medical equipment was visibly clean, the practice did not have cleaning records to reflect the cleaning of medical equipment. Staff we spoke with confirmed that medical equipment was cleaned before and after use.

  • The practice had a clear vision and there was a clear leadership structure in place. Staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider should make improvement are:

  • Ensure that the management of infection control is robust and reflects national guidance, including adequate record keeping to reflect the cleaning of medical equipment and to support the management of infection control.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice