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Inspection Summary


Overall summary & rating

Good

Updated 29 September 2016

Letter from the Chief Inspector of General Practice

We carried out a desktop review of St Mary’s Surgery on 21 September 2016. This review was performed to check on the progress of actions taken following an inspection we made in April 2015. Following that inspection the provider sent us an action plan which detailed the steps they would take to meet their breach of regulation. During our latest desktop review on 21 September 2016 we found the provider had made the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published in August 2016. This can be done by selecting the 'all reports' link for the St Mary’s Surgery on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

The practice had improved the systems ensuring that risk assessments and mandatory training was managed effectively so that patient safety is promoted and any risks that could affect the quality of care are reduced. This included:

  • Fire safety had been strengthened so that patients had safe exits in the event of a fire.

  • The chaperone policy and associated procedures had been reviewed to ensure that appropriate vetting and training took place of any staff undertaking these duties, promoting patient safety.

  • Implementation of a system of risk assessment for any new staff to determine whether a Disclosure and Barring Service check was required according to their role and responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 29 September 2016

The practice had improved the systems ensuring that patient safety was promoted and any risks that could affect the quality of care were reduced. This included:

  • Alterations to a fire door, including signage and the removal of a bolt to meet fire safety requirements.

  • The completion of a fire risk assessment and subsequent actions following the last inspection.

  • A system for carrying out Disclosure and Barring (DBS) checks for all staff undertaking chaperone duties.

  • The review and introduction of an updated chaperone policy, which outlined that only staff who have had appropriate checks and chaperone training provided support.

  • The introduction of a system of risk assessment for any new staff to determine whether a DBS was required or not according to their role and responsibilities.

Effective

Good

Updated 29 September 2016

Caring

Good

Updated 29 September 2016

Responsive

Outstanding

Updated 29 September 2016

Well-led

Good

Updated 29 September 2016

Checks on specific services

People with long term conditions

Good

Updated 3 September 2015

The practice is rated as good for the care of people with long-term conditions. All patients with long term conditions had an annual review and medication check. A specific template had been created to record care and identify risks to patients with long-term conditions such as diabetes and chronic obstructive pulmonary disease (COPD). Nurse led specialist clinics were held for patients with diabetes, asthma and COPD. Home visits were available for patients that could not access the surgery.

Families, children and young people

Good

Updated 3 September 2015

The practice is rated as good for the care of families, children and young people. Systems were in place to identify and follow up on those children and young people, who were at risk, including systems to identify and manage risks to the unborn child. An extended appointment service was available to provide appointments for school age children. The practice provided appointments on the same day for children and a children’s phlebotomy (blood taking) service was available on site. There was a health visitor clinic held at the site and the health visitor offered drop in clinics and first time parent classes.

Older people

Good

Updated 3 September 2015

The practice is rated as good for the care of older people. The practice offered proactive personalised care to meet the needs of older people in its population and had a range of enhanced services available. All patients over the age of 75 had a named GP. The practice provided a 60 minute health check for all patients over the age of 75 and had created a screening tool to record information as part of the health check. Older patients with complex needs had a care plan in place.

Working age people (including those recently retired and students)

Good

Updated 3 September 2015

The practice is rated as good for the care of working age people (including those recently retired and students). The practice provided care to a large student population. A total of 69% of the practice population were under the age of 35. The practice provided an extended hours service with GPs and nurses and telephone consultations were available. Repeat prescriptions and appointments could be requested on-line. Same day appointments were available every day and this helped people to get medical care quickly so that they could return to work. The practice had run a successful cervical screening campaign and this was supported by additional nurse clinics. This had increased the number of women who received cervical screening to 89.97% compared to the national average of 81.89%.

People experiencing poor mental health (including people with dementia)

Good

Updated 3 September 2015

The practice is rated as good for the care of people experiencing poor mental health. People who were experiencing poor mental health were supported by look after their physical health. A total of 93.8% of patients with poor mental health had their alcohol consumption discussed with them in the last year. A template had been instigated to assist in the assessment and documentation of care provided to people with poor mental health and their ability to make decision. A register of people experiencing poor mental health was available. All patients who did not attend for appointments were contacted by telephone.

The practice provided funding for fifteen hours of one to one counselling each week, which was made available to those patients who would not otherwise be eligible for a counselling service through any other route. Patients were encouraged and supported to access other services such as substance misuse services. A GP acted as lead for supporting patients who misused substances. This involved providing shared care controlled prescribing, with patients being reviewed every six months by the GP and a substance misuse counsellor.

A dementia screening tool had been created and was being used to assess patients who were at risk of dementia.

People whose circumstances may make them vulnerable

Good

Updated 3 September 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. The practice had created a safeguarding referral template and their safeguarding procedures had been implemented across the clinical commissioning group. Clinical alerts were placed on the system to identify patients whose circumstances made them vulnerable and staff had attended a practice based domestic violence and abuse training support and referral programme and completed training in communication.

Patients who had complex care needs were placed on a practice register and an admission avoidance scheme was in place. This had been put in place in response to a high number of hospital admission reported in 2013 to 2014. The number of emergency cancer admissions per 100 patients on disease register was 38.1 compared to the national average of 7.4. GPs told us that this had been reduced and patients receiving palliative care were placed on an end of life register and had two named GPs. Multi-disciplinary meetings were held with the district nursing team. The practice had increased the number of additional locum sessions from four sessions to seven sessions during the winter months and put in place a system where patients could be seen on the same day or early the next day to reduce the number of patients using out of hours services.

Over 25% of the practice population did not speak English as a first language. Staff had worked with a local voluntary organisation, which provided a radio station, catering to the Asian and ethnic minority communities in the area, to provide information to the local population about how to access the practice, influenza management and childhood immunisations. The practice had provided support to access healthcare to women in the local Afghan community. A GP told us that he met with a local Somali leader to provide information and discuss access to healthcare for the local Somali population. The practice had an automated check-in service, which could be operated in ten different languages. Translators and sign language support service were available.