Archived: St Mary's Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 12 April 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulations 12 and 17.

We undertook a focussed inspection on 22 November 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from March 2016 by selecting the ‘all reports’ link for St Mary’s Medical Centre on our website at www.cqc.co.uk

Overall the practice is now rated as Requires improvement. Safe remains as requires improvement and due to further improvements that are required well-led has dropped to requires improvement.

• Lessons learnt from significant events and complaints were shared with all staff within the practice.
• Risks to patients were assessed and managed, with the exception of those relating to premises, fire and legionella.
• The practice had a plan in place to ensure all staff had received Safeguarding training by the end of December 2016.
• The Disaster and Business Continuity Plan had been reviewed and mitigating risks and actions were documented.
• Refrigerator temperatures in all treatment rooms and corridors were checked and reset daily in line with practice policy.
• A system for the monitoring of staff training had been put in place but it required further work to ensure the training needs of staff had been met.

The areas where the provider must make improvement are:

• Ensure there is an effective governance system in place to identify and mitigate risks to patients and staff in relation to the completion of actions for premises, fire, legionella and prescription stationary. For example, emergency lighting and monthly monitoring of legionella water testing.
• Ensure the system for recording, investigating and monitoring of dispensary near-miss errors is effective and lessons are learnt.
• Embed the new system for the monitoring of staff training requirements.

The areas where the provider should make improvement are:

• Continue with the programme to have all staff up to date with safeguarding training by end of December 2016.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Mary’s Medical Centre on 12 April 2016. Overall the practice is rated as Good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Lessons learnt from significant events and complaints were not shared with all staff within the practice.
• Risks to patients were assessed and managed, with the exception of those relating to premises, fire and legionella.
• 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.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were available on a daily basis but some found it difficult to make an appointment with a named GP for continuity of care.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. However the management team did not provide all staff with sufficient oversight of governance issues such as significant events and complaints.
• The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

• Ensure there is an effective governance system in place to identify and mitigate risks to patients and staff in relation to the completion of actions for premises, fire and legionella.

• Implement a policy for legionella and commence monthly water testing as per legionella risk assessment.

• Ensure lessons learnt from significant events and complaints are shared with all staff within the practice.

• Ensure all staff receive training in safeguarding adults and children including reception and administrative staff. All GPs need to be trained to level 3 and nurses to level 2.

• Maintain a training matrix and ensure that all mandatory training requirements are met by all staff.

The areas where the provider should make improvement are:

• Improve the coding for vulnerable adults on the patient record system

• Ensure all staff have an awareness of Mental Capacity Act 2005

• Embed a system where all fridge temperatures in all treatment rooms and corridors are checked and reset in line with practice policy.
• Ensure Dispensary near misses are recorded to ensure lessons are learnt
• Within the disaster and business Continuity Plan ensure mitigating risks and actions are included.

• Complete recruitment checks/DBS of volunteer drivers who deliver medicines to patients

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice