Archived: St Mary's Road Surgery

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of the St Mary’s Road Surgery on 13 June 2015. Overall the practice is rated as good.

We found the practice to be good for providing effective, caring, well-led and responsive services. It required improvement for providing safe services. It was good at providing services for all the population groups including older people; people with long term conditions; mothers, babies, children and young people; the working age populations and those recently retired; people in vulnerable circumstances and people experiencing poor mental health.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.

• Patients’ needs were assessed and care was planned and delivered following 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 about services and how to complain was available and easy to understand.
• 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.
• Risks to patients were assessed and well managed.

We saw one area of outstanding practice:

• The practice offered in house ultrasound service to patients. Two GPs were trained to offer this service and were able to carry out scans for pregnant women in early pregnancy and identify any problems quickly and efficiently. This also meant patients did not have to be referred to local hospital to access this service.

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

Importantly the provider must:

• Ensure all staff identified as requiring a criminal records check through the Disclosure and Barring Service (DBS) have one undertaken as soon as possible.
• Ensure all recruitment and employment information required by the regulations are documented in all staff members’ personnel files.
• Ensure all relevant risk assessments are completed. This includes risk assessments in areas such as, fire, legionella and infection control.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice