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Inspection Summary

Overall summary & rating


Updated 18 September 2018

We undertook an announced focused inspection of St Melor House Surgery on 20 December 2017. This was to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous (follow-up, desk based) inspection on 19 June 2017. At that inspection the practice continued to be rated as Good overall. The practice continued to be rated as Requires Improvement for providing effective services, because not all of the mandatory training we had identified as not being completed at our June 2017 inspection had been completed. The reports of the follow up inspections carried out on 19 June 2017 and 20 December 2017, can be found by selecting the ‘all reports’ link for St Melor House Surgery on our website at

This report covers the announced focused follow-up inspection we undertook at St Melor House Surgery on 14 August 2018, to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection on 20 December 2017.

Our key findings were as follows:

  • All clinical staff had received training relevant to their role.
  • All staff had completed mandatory training.
  • The practice had reviewed their policies and procedures for identifying essential training appropriate to each staff member and communicated this requirement to staff.
  • The practice continued to work to develop a mechanism for gathering feedback from patients. Specifically:

    • The practice had taken steps to develop a patient participation group, by advertising for members on the practice website and also on a noticeboard in the practice reception area. A patient participation group was formed in December 2017 and we saw agendas and minutes of meetings held in January 2018 and June 2018. Going forwards, the group plans to meet twice-yearly.
    • We saw documentary evidence that the practice is collating and analysing the results of a recent patient survey. The practice told us the results will be published in the next few months.

Overall the practice continues to be rated as Good, and is now rated Good for providing effective services.

Inspection areas





Updated 18 September 2018

The practice is now rated as Good for providing effective services.

When we carried out a follow-up, desk-based inspection of St Melor House Surgery on 20 December 2017 we found there continued to be breaches of the regulations relating to staffing. Specifically:

  • One clinician had not received Mental Capacity Act (MCA) training and another had not received fire awareness training.

The practice had made improvements to the other areas previously in breach.

At this inspection, we focused on the area identified as in breach of regulation but also reviewed all areas of the key question to provide assurances that the practice were providing effective services. At this inspection we saw documentary evidence that showed:

  • All relevant staff had completed Mental Capacity Act (MCA) training. We saw documentary evidence that the practice had a training matrix which scheduled mandatory and other training when due for renewal.

We saw minutes of staff meetings, and appraisal meetings, which showed that training requirements were formally communicated to and discussed with staff.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The practice computer systems enabled them to check patients’ treatments against best practice guidance, to improve their health outcomes and to monitor performance against the QOF.
  • Staff used appropriate tools to assess the level of pain in patients.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Population Groups

We reviewed the QOF data which remained unchanged from the previous inspection. The data was in line with local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity, which included conducting clinical audits, and routinely reviewing the effectiveness and appropriateness of the care provided.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. This included an induction process, one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

The practice monitored the process for seeking consent appropriately.

Please refer to the Evidence Tables for further information.






Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable