St Mary's Surgery

Updated 23 August 2019

St Marys surgery is registered with the Care Quality Commission (CQC) as a partnership GP provider located in Ely Cambridgeshire and is a dispensing GP. The practice area covers the city of Ely, 11 local villages in the surrounding rural area. The practice has 15,600 registered patients. The practice is part of the NHS Cambridgeshire and Peterborough Clinical Commissioning Group and holds a General Medical Services (GMS) contract with NHS England.

According to Public Health England data, 25% of the registered patients are over the age of 65, this is above local and national averages. The practice demography differs slightly to the national average, with less 15-29-year olds and more 70-79 year olds. Male and female life expectancy in this area is in line with the England average at 82 years for men and 86 years for women. Income deprivation affecting children is 9%, which is below the England average of 15% and the CCG average of 21%. Income deprivation affecting older people is 11% which is below the England average of 20% and the CCG average of 19%.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. Premises are purpose built with administration offices situated nearby.

The practice has a team of ten GPs meeting patients' needs. Five salaried GPs are partners, meaning they hold managerial and financial responsibility for the practice, with five GPs providing sessional clinical support. There are four clinical practitioners who have their own patient consultations. There is a team of nine nurses including; one clinical nurse manager and eight practice nurses who are supported by six health care assistants.

The practice manager and deputy practice manager are supported by an IT manager, office manager and a team of non-clinical administrative and reception staff. There is a dispensary manager supported by a team of dispensers.

The surgery is open between 8am and 6.30pm Monday and Friday, evening GP appointments beyond 6.30pm are available on a Monday and Wednesday for GP appointments.

Updated 23 August 2019

We carried out an announced focused inspection at St Marys Surgery on 24 July 2019. We decided to undertake this inspection following our annual review of the information available to us. This inspection looked at the following key questions; safe, effective and well-led. Caring and Responsive were not reviewed because patient feedback and monitoring indicated no change since the last inspection. The rating from the last inspection has been carried forward.

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.

•Information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse. Staff spoken with understood their responsibilities.
• The practice learned and made improvements when things went wrong. Leaders promoted a culture of reporting and recording all incidents, including near misses, as significant events. These were reviewed monthly and an annual review undertaken to identify themes and trends.
• The practice understood the needs of its population and tailored services in response to those needs.
• Staff had the skills, knowledge and experience to deliver effective care, support and treatment and worked together and with other organisations to deliver effective care and treatment.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. All clinicians were up to date with guidance.
• Staff felt supported by the management team, proud to work at the practice and able to raise concerns.
• The practice responded to patient feedback and had made changes that had been suggested by their patient participation group
• There was compassionate, inclusive and effective leadership. Leaders were visible and approachable and understood the strengths and challenges of the services provided.

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

• Review the system and process to ensure all medical alerts are received, acted upon and monitored in a timely manner.

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

Updated 23 August 2019

Updated 23 August 2019

Updated 23 August 2019

Updated 23 August 2019

Updated 23 August 2019

Updated 23 August 2019