We carried out a review of the data available to us about St Davids Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Davids Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection of St Davids Practice on 24 October 2016. The overall rating for the practice was good with requires improvement in Safe. Breaches of legal requirements were found relating to the Safe domain. The registered person did not have a clear process in place for analysing significant events, incidents and near misses. The provider did not ensure that there was a defibrillator available at the practice or conduct a risk assessment to indicate the risks of not having one had been assessed.
After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report can be found by selecting the ‘all reports’ link for St Davids Practice on our website at www.cqc.org.uk.
This inspection was a document-based review carried out on 12 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 24 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
The practice is now rated as Good for providing Safe services, and overall the practice remains rated as Good.
Our key findings were as follows:
The practice had reviewed its policy on safeguarding and its process for recording and reporting safeguarding concerns. We saw a revised policy, we saw comprehensive safeguarding minutes, detailing all safeguarding cases, including a description, action plan and learning points.
The practice had reviewed its policy on significant events we saw a revised policy detailing the process for recording and reporting all significant events. We saw comprehensive minutes of significant events and analysis meeting minutes detailing five significant events that had occurred between May and July 2017, including case discussions, reflection, actions taken and lessons learnt.
The practice had carried out a risk assessment on 14 April 2017 to demonstrate that they had considered and mitigated against the risk of not having access to their own defibrillator.
The practice also submitted a written agreement to confirm arrangements were in place to borrow a defibrillator from the practice they shared premises with. However, whilst it was signed by both parties there was no date.
The practice had reviewed its policy on carers. We saw a revised policy detailing the process for identifying and registering new carers. The practice had now identified (47 patients) as carers 0.6% this had increased by 0.1% since the last inspection.
The area where the provider should make improvements are:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Davids Practice on 24 October 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The practice had a system in place for reporting and recording safeguarding concerns; however, not all relevant incidents were recorded as safeguarding concerns, and therefore opportunities to learn from these incidents were sometimes missed.
Risks to patients were mostly assessed and well managed. However, the practice did not have their own defibrillator available or a risk assessment to show that they had considered and mitigated against the risk of not having one.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
The areas where the provider must make improvement are:
The provider must review their process for recording and reporting safeguarding concerns to ensure that all staff are aware of the threshold for reporting and recording a safeguarding concern and that lessons learned are appropriately shared and embedded.
Ensure that the practice has a defibrillator available to respond to medical emergencies or to have completed a risk assessment identifying how they would deal with medical emergencies.
The areas where the provider should make improvement are:
Revise arrangements in place to ensure that patients with caring responsibilities are identified, so their needs are identified and can be met.
Chief Inspector of General Practice