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Stuart Crescent Medical Practice Requires improvement

Reports


Inspection carried out on 5 February 2020

During an inspection looking at part of the service

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions, effective, caring, responsive and well led.

At our inspection in January 2017, we rated the practice as Requires Improvement for providing safe and well-led services. At this time included amongst the issues we identified, was the practice did not have adequate management and storage of medicines and medical devices held on site. In addition, the practice did not engage fully with its patients to assist in establishing a patient participation group (PPG), which would serve as a channel to address patient concerns as highlighted in the low scores the practice received as part of the National GP Patient Survey. Finally, there was limited evidence that all non-clinical staff had received an appraisal during the preceding 12 months as well as recent information governance training.

We carried out an announced focused inspection on 16 October 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 4 January 2017. We found that the practice had made improvements to provide safe and well-led services. As a result of these findings, the practice was rated as good for providing safe and well-led services.

At this inspection (5 February 2020), 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.

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for effective because:

  • The practice had not met national targets for the cervical cancer screening programme.
  • The practice had not met World Health Organisation (WHO) targets for the childhood immunisation programme.

We rated the practice as requires improvement for caring because:

  • The practice received low scores in the national patient survey in relation to caring. The practice had undertaken their own internal practice survey however, this was from a small number of patients and not representative of the practice population.

We rated the practice as good for providing a responsive and well-led service because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Take action to improve the uptake for the childhood immunisation programme.
  • Take action to improve the uptake for the cervical cancer screening programme.
  • Extend the practice patient survey to include a wider number of the patient population.

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 carried out on 16 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr M.S.Dave & Dr G Mangaleswaradevi (known as Stuart Crescent Medical Practice) on 4 January 2017. The overall rating for the practice was Requires Improvement. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr M.S.Dave & Dr G Mangaleswaradevi on our website at www.cqc.org.uk.

At our previous inspection in January 2017, we rated the practice as Requires Improvement for providing safe and well-led services. At this time included amongst the issues we identified, was the practice did not have adequate management and storage of medicines and medical devices held on site. In addition, the practice did not engage fully with its patients to assist in establishing a patient participation group (PPG), which would serve as a channel to address patient concerns as highlighted in the low scores the practice received as part of the National GP Patient Survey. Finally, there was limited evidence that all non-clinical staff had received an appraisal during the preceding 12 months as well as recent information governance training.

This inspection was an announced focused inspection carried out on 16 October 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 4 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe and well-led services. As a result of these findings, the practice is now rated as good for providing safe and well-led services.

The change in the ratings for the key questions of safe and well-led, means that the practice is now rated as good overall.

Our key findings were as follows:

  • Risk to patients were assessed and managed correctly. For example, all medicines and medical devices stored at the practice that we viewed were in date.
  • The practice reviewed its provision of nursing services, and as a result now employed a practice nurse who conducted sessions four times a week.
  • We saw evidence that staff had conducted recent information governance training.
  • The practice had engaged with patients with a view to establishing a patient participation group (PPG).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 4 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr M Dave & Dr G Mangaleswaradevi (known as Stuart Crescent Medical Practice) on 4 January 2017. Overall the practice is rated as Requires Improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. 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 number of policies and procedures to govern activities, which were reviewed regularly.
  • Risks to patients were not always assessed and managed. For example on, the day of inspection we found out of date medicines and medical devices, which were destroyed promptly.
  • Data showed patient outcomes were comparable to the local and national averages. We saw evidence of audits which were providing direction for improvements to patient outcomes.
  • Patient comment cards received revealed patients were treated with compassion, dignity and respect.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • There was no evidence that non-clinical staff had received an appraisal during the past 12 months.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Not all members of staff had received information governance training during the past 12 months.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • The practice did not have an active Patient Participation Group (PPG). The practice was currently running a campaign to recruit members.

The areas where the provider must make improvements are:-

  • To ensure the safe and proper management of medicines and medical devices, specifically relating to the storage and monitoring of expiry dates of vaccines, medicines and medical devices held at the practice.
  • Ensure effective and sustainable governance systems and processes are implemented to assess the quality of services provided, in particular in relation to establishing and maintaining a Patient Participation Group and to address low scores practice received as part of the National GP Patient Survey.

In addition the provider should:

  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
  • Ensure all members of staff undertake information governance training periodically.
  • Assign a member of clinical staff to oversee and implement the functions associated with nursing staff.
  • Have a documented strategy and supporting business plans which reflect the vision of the practice and ensure all members of staff are familiar with the practice mission statement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice