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Review carried out on 5 December 2019

During an annual regulatory review

We reviewed the information available to us about Mark Street Surgery on 5 December 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 20 November 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating February 2015 – Good)

The key questions at the inspection in February 2015 were rated as:

Are services safe? – Good

Are services effective? – Outstanding

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Mark Street Surgery on 20 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice strongly supported staff in their career development.
  • The practice, with other practices in the Clinical Commissioning Group and the wider NHS, had receptionists who were trained as care navigators who signposted patients to the right person at the right time across a variety of health services.

We saw areas of outstanding practice:

  • The practice carried out an ongoing workforce assessment to keep up to date with fluctuations in staff and the quantity and type of work that they required to do.
  • They invested heavily in both clinical and non- clinical staff training and development with one of the results of increasing clinical sessions and appointments available to patients.

The areas where the provider should make improvements are:

  • The practice should carry out a risk assessment and consider its emergency drug stock.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 25 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mark Street Surgery on 25 February 2015

Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also outstanding for providing services for patients with long-term conditions

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • Risks to patients were assessed and well managed.

  • Patients’ needs were assessed and care was planned and delivered after considering best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
  • The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We also saw areas of outstanding practice:

  • The practice held twice monthly early morning diabetic meetings. Clinicians reviewed patients, care and treatments strategies, best practice and research guidelines and invited speakers to promote staff’s learning and development.

  • The practice actively screened patient blood test results to identify those that were pre-diabetic. Those identified were invited in to an appointment to discuss the risk of developing diabetes and review lifestyle choices to mitigate this risk.

  • The practice provided a carer’s advocacy support service. The name and contact details of the carer’s advocate was displayed in the patient waiting area. In addition, three reception staff were trained as part of the practice’s carer’s resource team.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

Ensure a standardised approach to recording written consent from patients before any minor surgery procedure.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice