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St Georges Surgery Good Also known as Drs Pollock, Buckley, Ashe, Rosbottom and Almond

Reports


Inspection carried out on 17/07/2019 to 17/07/2019

During a routine inspection

We carried out an announced comprehensive follow up inspection at St Georges Surgery on 17 July 2019. We undertook this inspection following an inspection in October 2018. At that time, we rated the service as Requires Improvement. We issued the provider with a requirement notice for a breaches of regulation 19, fit and proper persons and Regulation 17 good governance. The full report from our October 2018 inspection visit can be found here www.cqc.org.uk

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.

We have rated this practice as good overall and good for all population groups.

We found that:

  • The surgery had made improvements in the way they disseminated patient safety alerts and stored blank prescriptions.
  • Patients received effective care and treatment that met their needs.
  • There were comprehensive quality assurance systems in place that were underpinned by consistent monitoring.
  • Patients commented that staff were caring and professional.
  • Staff were well trained and competent in the delivery of good patient care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

  • Continue to develop the way significant events and incidents are analysed.
  • Continue to develop the way complaints are investigated and responded to.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 25 October to 25 October 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating February 2015 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

We carried out an announced comprehensive inspection at St Georges Surgery on 25 October 2018 as part of our inspection programme.

At this inspection we found:

  • There were gaps in the practice’s governance arrangements resulting in risk management processes not being comprehensive, for example in respect to recruitment procedures and training oversight.
  • While the practice had a range of documented policies and procedures in place, we found examples where these had not been followed.
  • The practice had systems to identify and investigate safety incidents so that they were less likely to happen again. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Feedback from patients was consistently and strongly positive about the quality of care and treatment offered by the practice.
  • The practice had a well-managed appointment system which facilitated timely access for patients.
  • Staff told us of a strong team ethos at the practice and that they felt supported by the partners and management.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

  • Maintain a log of patient safety alerts which contains sufficient detail so as to be assured that any necessary actions have been completed.
  • Communication channels should be formalised to ensure learning from significant events and complaints is maximised and shared efficiently with the wider practice team.
  • Risks associated with the storage of blank printer prescription paper should be assessed and mitigating actions taken as necessary.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 18 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook an inspection of Dr R S Pollock’s Practice on 18 November 2014 as part of our new comprehensive inspection programme. We looked at how well the practice provided services for all population groups of patients. The inspection took place at the same time as other inspections of GP practices across Blackburn with Darwen Clinical Commissioning Group.

The practice was rated as good overall.

Our key findings were as follows:

  • Care was provided in an environment which was clean and well organised

  • Feedback from patients about their care and treatment was consistently positive.

  • We found the practice had a strong team based ethos and this was reflected across all staff.

  • Systems were in place to ensure information about safety was recorded, monitored, reviewed and actioned.

  • The Patient Participation Group (PPG) was effective in promoting changes and the Chair was proactive in engaging with the locality practices and Clinical Commissioning Group.

We saw several areas of outstanding practice including:

  • Work with the self-care coordinator was improving care, treatment and outcomes for patients with long term conditions

  • The practice worked closely with the district nurses and other community services in the implementation of a virtual ward providing care and treatment in patients’ homes. This provided intensive support for patients with complex care needs or who were particularly frail and elderly and avoided unnecessary hospital admission.

  • A direct telephone line was available for appointments for all patients with long term conditions and a care plan.

  • We were made aware that the GPs gave their own telephone number out of hours to patients and visited those who were terminally ill or approaching end of life , even though they were not on call and services were delegated to the out of hours provider.

  • Staff were aware on a daily basis if any patient’s condition had deteriorated by means of a TLC board. Kept in the administration office, this was used to raise awareness amongst staff of any concerns about patients.

However, there were also areas of practice where the provider needs to make improvements.

In addition the provider should:

  • Ensure there is formal policy guidance for staff in respect of medicines management and significant event management.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice