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Reports


Review carried out on 22 January 2020

During an annual regulatory review

We reviewed the information available to us about St Melor House Surgery on 22 January 2020. 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 14 August to 14 August

During an inspection looking at part of the service

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 www.cqc.org.uk.

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 carried out on 20 December 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

When we undertook a comprehensive inspection of St Melor House

Surgery on 29 November 2016 we found a number of regulatory breaches and the

practice was rated as requires improvement. We undertook a follow up desk-based

inspection of St Melor House Surgery on 19 June 2017 to review the actions

taken by the practice to improve the quality of care and to confirm that the

practice was meeting legal requirements. We found that the practice had made

significant improvements although they were still in breach of the regulations

relating to staffing. We amended our rating of the practice so it was rated

Good overall and for providing Safe, Caring, Responsive and Well-led services,

and rated as Requires Improvement for the provision of Effective services.

We said that they must:

  • Ensure staff receive the essential training appropriate to their

    role.

We also said they should:

  • Continue to work to encourage patients to join and participate

    in the patient participation group.

The reports of the full comprehensive inspection carried out on

29 November 2016 and follow up desk-based focused inspection carried out on 19

June 2017 can be found by selecting the ‘all reports’ link for St Melor House

Surgery on our website at

www.cqc.org.uk

.

This report covers the announced focused inspection visit we

carried out at 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 inspection on 19 June

2017.

Overall the practice continues

to be rated as Good and requires Improvement for providing effective services.

Our key findings were as follows:

  • We saw evidence that most of the mandatory training we had

    identified as not being completed at our last inspection had now been

    completed. For example, all the GPs had been trained to level three in child

    safeguarding.

  • We found that

    one clinician had not received Mental Capacity Act (MCA) training and another

    had not received fire awareness training.

  • The practice

    had taken steps to encourage patients to join the patient participation group. A

    meeting date had been agreed and we saw evidence some patients had confirmed

    they wished to attend.

There were areas of practice where the provider needs to make

improvements. Importantly, the provider must:

  • Ensure staff

    receive the essential training appropriate to their role.

     

In addition the provider should:

  • Review their policies and procedures for identifying essential

    training appropriate to each staff member and communicating this requirement to

    staff.

  • Continue to work to develop a mechanism for gathering feedback

    from patients.

     

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on This inspection was carried out without visiting the practice on 19 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

When we visited St Melor House Surgery on 29 November 2016 to carry out a comprehensive inspection we rated them as requires improvement overall. We found breaches in the regulations relating to safe, effective and well-led services, and we told the practice they must:

  • Ensure all staff receive essential training such as safeguarding training and infection control training to a level appropriate to their role.

  • Ensure staff and patients are protected by conducting regular fire drills.

  • Ensure the practice has a policy and procedure on safeguarding which includes details of the safeguarding lead.

  • Ensure all appropriate recruitment checks are carried out and recorded prior to employing new staff.

We also said they should;

  • Ensure all policies are kept up to date

  • Ensure the practices policies on safeguarding and significant events are embedded in the practice routine operations.

  • Ensure the practice process and procedure for managing complaints is used consistently.

  • Ensure that the practice develops effective strategies for encouraging patient participation in their patient participation group, and listening and responding to patient feedback.

  • Ensure all sharp bins

    are appropriately labelled when placed into service.

This inspection was an announced focused inspection carried out on 6 June 2017, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. This report should be read in conjunction with the full report of our inspection on 29 November 2016, which can be found on our website at

www.cqc.org.uk.

The practice is now rated as good for the provision of safe and well-led services and requires improvement for the provision of effective services. Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had a safeguarding policy which included details of the safeguarding lead.

  • The practice had reviewed their fire safety policy and had conducted a fire evacuation drill.

  • Some staff had received training since our previous inspection. However, there were still staff who had not received the training essential to their role.  

  • The practice had reviewed their clinical governance arrangements, which included dealing with complaints, to ensure their systems, policies and procedures were understood by all staff and embedded in routine operations.

However, there remain areas where the provider must make improvement. The practice must:

  • Ensure staff receive the essential training appropriate to their role.

There was one area where the provider should make improvement.

  • The practice should continue to work to encourage patients to join and participate in the patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 29 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Melor House Surgery on 29 November 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • The practice did not have written policies or procedures setting out how significant events or safeguarding concerns should be managed.

  • Apart from one member of staff, the practice had no evidence that any other staff had received training in infection control, Mental Capacity Act 2005, health and safety or fire training. Not all staff had been trained to the recommended level in child safeguarding appropriate to their role.

  • The practice did not always carry out all the appropriate recruitment checks prior to employing staff.

  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and fire drills.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • The practice was above average for its satisfaction scores on consultations with GPs and nurses. For example, 96% of patients said the last GP they spoke with was good at treating them with care and concern compared to the clinical commissioning group average of 89% and national average of 85%.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • Information about services and how to complain was available and easy to understand. . However, the practice system for reviewing complaints was not always used consistently.

  • 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure all staff receive essential training such as safeguarding training and infection control training to a level appropriate to their role.

  • Ensure staff and patients are protected by conducting regular fire drills.

  • Ensure the practice has a policy and procedure on safeguarding which includes details of the safeguarding lead.

  • Ensure all appropriate recruitment checks are carried out and recorded prior to employing new staff.

The areas where the provider should make improvement are:

  • Ensure all policies such as those relating to are kept up to date

  • Ensure the practices policies on safeguarding and significant events are embedded in the practice routine operations.

  • Ensure the practice process and procedure for managing complaints is used consistently.

  • Ensure that the practice develops effective strategies for encouraging patient participation in their patient participation group, and listening and responding to patient feedback.

  • Ensure all sharp bins are appropriately labelled when placed into service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice