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Inspection carried out on 24/07/2019

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

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

Inspection carried out on 16 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Mary’s Surgery on 16 July 2015. Overall the practice is rated as good.

We found the practice to be safe, effective, caring, responsive to people’s needs and well-led. The quality of care experienced by older people, by people with long term conditions and by families, children and young people was good. Working age people, those in vulnerable circumstances and people experiencing poor mental health also received good quality care.

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.
  • Risks to patients were assessed and well managed. Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • 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.
  • Patients said they were treated as individuals and that they were involved in their care and decisions about their treatment. Patients described the practice as caring, helpful and friendly.
  • Patients could speak on the telephone and make an appointment with a named GP. Routine as well as urgent appointments were available on the same day.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned. The practice valued the importance of quality, improvement and learning and were actively involved in clinicians’ education and training and in primary care research.
  • There was a clear leadership structure and staff felt supported by management. The practice worked closely with its patient participation group and proactively sought feedback from staff and patients. They listened to what patients told them and made improvements accordingly.

We saw areas of outstanding practice:

  • The practice provided International Normalized Ratio or INR blood monitoring (a blood test to review and monitor the effectiveness of long term blood thinning medication), for their patients as evening appointments, as a domiciliary service for housebound patients and from a local supermarket.

  • The practice was committed to primary care development and education. They took an active part in clinicians’ education and primary care research and encouraged staff at all levels to develop their knowledge and skills.
  • GPs provided 24 hour cover, seven days a week, to an inpatient rehabilitation ward at a local hospital and often provided patients on end of life care personal 24 hour and weekend contact information to ensure continuity of care.
  • Practice information was available in a number of languages both on the practice website and within the practice. The practice also provided sign language support for patients with reduced hearing and large font for both practice information and the website for patients with limited visibility.

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

Importantly the provider should;

  • Improve the arrangements for the security of blank prescription forms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

We carried out this follow up review to check the actions the provider had taken to address the compliance action made at the previous inspection in September 2013. We followed up one outcome area of non-compliance identified in the previous inspection in September 2013. The evidence that we reviewed demonstrated the provider was compliant with this essential standard.

Inspection carried out on 5 September 2013

During a routine inspection

We spoke with several people who attended the surgery during the course of this inspection. All of the people we spoke with made positive comments about the friendly attitude of the doctors and nurses. We noted that nurses and doctors met and greeted people in the waiting room and escorted them to the treatment rooms. One person said, "I have usually been treated with respect by all staff and doctors. I have no complaints to make".

A mother with their child made a less positive comment about how it had taken them a longer than satisfactory time to arrange an emergency appointment for her baby by telephone. Overall, every person we spoke with told us they had managed to arrange an appointment for the same day, when it had been necessary.

We found some concerns about the management of medication that was collected by people from their local village store and out of date vaccines kept at the surgery.

The premises appeared to be clean and well maintained, although certain pieces of furniture and furnishings presented a hygiene risk.

Staff reported they had received suitable support and supervision from their managers.