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Reports


Review carried out on 7 August 2019

During an annual regulatory review

We reviewed the information available to us about St Davids Practice on 7 August 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 12 September 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

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:

  • Continue to review arrangements in place to ensure that patients with caring responsibilities are identified and their needs met.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 24 October 2016

During a routine inspection

Letter from the 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:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • 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.

  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • There was a clear leadership structure and staff felt supported by management. 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:

  • 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice