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St Clements Partnership Good

Inspection Summary


Overall summary & rating

Good

Updated 20 April 2020

We carried out an announced focused inspection at St Clements Partnership on 11 February 2020 to follow up on a previous breach of regulation. Prior to our inspection, we completed a review of this service following our annual regulatory review of the information available to us. This inspection looked at the following key questions:

  • Is the service providing safe services?
  • Is the service providing effective services?
  • Is the service providing well-led services?

The practice’s annual regulatory review did not indicate that the quality of care had changed in relation to Caring and Responsive. As a result, the ratings from the practice’s previous inspection from 2019 still stand in those key questions.

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, in January 2019, we rated the practice Good overall but Requires Improvement for providing safe services.

At this inspection, in February 2020, we have continued to rate the practice as Good overall but Requires Improvement for providing safe services.

We have continued to rate the practice as

R

equires Improvement

for providing safe services because, although the practice had made some progress in addressing its previous areas of non-compliance, we identified new areas of concern at this inspection:

  • The practice’s infection prevention and control measures had deteriorated since our last inspection in relation to the practice’s general cleanliness and the monitoring of water temperatures to prevent the risk of legionella.
  • There were gaps in staff compliance with infection prevention and control training.
  • There was no system to ensure the actions following receipt of safety alerts had been acted upon.

We rated the practice as

Good

for providing effective and well-led services because:

  • Patients received effective care and treatment that met their needs.
  • Clinical audits were used effectively to identify and drive areas for improvement.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We continued to rate the population group for people whose circumstances make them vulnerable as

Outstanding

because:

  • The practice had continued its bespoke work with a local homeless centre, supporting patients with opioid and substance misuse and had reduced prescribing rates accordingly.

We continued to rate the population group for working-age people as

Requires Improvement

because:

  • The practice continued to be below the national target for cervical screening uptake with a less than 70% uptake.

The areas where the provider

must

make improvements are:

  • Ensure that care and treatment is provided in a safe way.

(Please see the specific details on action required at the end of this report).

The areas where the provider

should

make improvements are:

  • Review the practice’s storage arrangements of medicines to be in line with national guidance.
  • Review the practice’s training requirements to reflect the recommendations of national guidance, particularly in relation to safeguarding children and adults.
  • Continue to encourage the uptake for cervical screening and childhood immunisations to achieve the relevant national targets.
  • Continue to encourage uptake of annual reviews to improve patient outcomes.
  • Amend the practice’s business continuity plan to accurately reflect the practice’s current staffing arrangements.
  • Establish a virtual patient participation group to seek formal patient feedback to drive improvement at the practice.
  • Seek assurances that staff are following correct procedures relating to information governance, for example, the implementation of appropriate security measures when staff are away from their computers.

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 areas

Safe

Requires improvement

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Outstanding