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St Mary Street Surgery Good Also known as Drs Williams, McCulloch, Kerr & Harrison

Inspection Summary


Overall summary & rating

Good

Updated 27 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of St Mary Street Surgery on 24 May 2016. The overall rating for the practice was requires improvement, with the safe and well-led domains rated as requiring improvement. The provider had resolved some of the concerns for the safe and well-led domains at our focused follow-up inspection on 28 February 2017. However, the provider had not rectified all the issues found previously in our comprehensive inspection and the practice remained as requiring improvement for providing safe and well-led services. Following the focused follow-up inspection we again issued two requirement notices. A notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment; and a notice was issued due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to good governance.

Within our last inspection report we reported that the provider must:

  • Ensure that confidential records, including patient medical records, were held securely at all times and within appropriate containers to remove the risk of damage and destruction.
  • Ensure that all actions from the fire risk assessment had been completed including the electrical installation safety check, to ensure staff were appropriately trained in fire safety including key members of staff who led the team and patients to safety.

In addition, the provider should:

  • Ensure blank prescription paper and pads were kept secure at all times.
  • Ensure formal risk assessments took place when staff were employed before all appropriate checks had been received.
  • Ensure actions, as identified from the practice legionella risk assessment were carried out.
  • Improve its systems on how it monitored the quality of care and treatment provided to its patients, and ensure that when auditing took place this was discussed with all of the clinical team to share learning.

We found the practice needed to improve its systems on how it monitored the quality of the care and treatment provided to its patients. For example, minor surgery results were not monitored for complications or for diagnostic accuracy.

The comprehensive and focused follow-up inspection reports can be found by selecting the ‘all reports’ link for St Mary Street Surgery on our website at www.cqc.org.uk.

We undertook a subsequent focused follow-up inspection of the practice on 3 July 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

There were key findings across all the areas we inspected during this follow-up inspection. We saw documentary and other evidence that:

  • The practice had assigned a dedicated room for medical records storage. The records were held in appropriate containers and the room had a lockable door that could only be accessed with a key, which was accessible by certain staff. In addition, we saw that blank prescription paper and pads were kept secure at all times behind locked doors that were only accessible to authorised staff.

  • All actions from the fire risk assessment had been completed, including an electrical installation safety check. Fire warden training had been completed by key members of staff responsible for team and patient safety.

In addition, we saw documentary and other evidence that:

  • The practice had a formal risk assessment in place if non-clinical staff were employed before all appropriate checks had been received.
  • Actions identified from the practice legionella risk assessment had been carried out. These included a record of weekly water system flushing.
  • Clinical audits had been completed and findings discussed with all the clinical team to share learning.

Following this inspection the practice was rated as good across all domains.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 27 July 2017

The domain for safe is now rated as good. This is because, during our focused inspection on 3 July 2017, we found:

  • All actions from the fire risk assessment had been completed, including an electrical installation safety check. Fire warden training had been completed by key members of staff responsible for team and patient safety.
  • Blank prescription paper and pads were kept secure at all times.

  • The practice had a formal risk assessment in place if non-clinical staff were employed before all appropriate checks were received. The written risk assessment also covered previous employment references, and evidence of a Disclosure and Barring Service (DBS) check.

  • All actions identified from the practice legionella risk assessment had been carried out.

Effective

Good

Updated 18 July 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all clinical staff and a plan in place to extend this to all staff employed at the practice by July 2016.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 18 July 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.

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

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 18 July 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and clinical commissioning group to secure improvements to services where these were identified.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

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

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 27 July 2017

The domain for well-led is now rated as good. This is because, during our focused inspection on 3 July 2017, we found:

  • The practice had assigned a dedicated room for medical records storage. The records were held in appropriate containers and the room had a lockable door that was secured by lock and key and could only be accessed by staff. In addition, we saw that blank prescription paper and pads were kept secure at all times behind locked doors that were only accessible to staff.

  • Clinical audits had been completed and findings discussed with all the clinical team to share learning.
Checks on specific services

People with long term conditions

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 27 July 2017

The provider had resolved the concerns for safe and well-led services as identified at our inspection on 3 July 2017 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.