We carried out a review of the data available to us about St Margaret's Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Margaret's Medical Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection of St Margaret’s Medical Practice on 27 January 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment), 13 (Safeguarding services users from abuse and improper treatment), 17 (Good governance), and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook an unannounced focussed inspection on 10 October 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. During this inspection we found that some areas had been addressed but that some actions had not yet been put in place; we also found some further areas of concern, which required further investigation. Therefore, the decision was made to extend the focussed inspection to a full comprehensive inspection, and we returned to the practice for an announced visit on 1 November 2016 in order to consider the areas which had not been covered during the focussed inspection and to look in further detail into the further areas of concern we had noted.
Following the further inspections, the practice submitted an action plan, outlining the further actions that they would carry-out to address the additional issues identified. On 23 August 2017 we contacted the practice and asked them to send us evidence that they had followed their action plan, in order for us to undertake a focussed desk-based inspection. This information was received on 25 September 2017. This report covers our findings from the desk-based inspection of 25 September 2017. You can read the reports from the previous inspections by selecting the ‘all reports’ link for St Margaret’s Medical Practice on our website at www.cqc.org.uk.
Overall the practice was rated as requires improvement following the initial comprehensive inspection on 27 January 2016. They were rated as requires improvement for providing safe and effective services and for being well led. Following the re- inspection in October & November 2016 we rated the practice as good overall. We rated them as requires improvement for providing a safe service and good for providing an effective service and for being well led. The inspection of 25 September 2017 looked only at the safe domain and rated this as good.
Our key findings were as follows:
The areas where the provider should make improvement are:
Professor Steve Field CBE FRCP FFPH FRCGPChief
Inspector of General Practice
We carried out an announced comprehensive inspection of St Margaret’s Medical Practice on 27 January 2016 . Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment), 13 (Safeguarding services users from abuse and improper treatment), 17 (Good governance), and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook an unannounced focussed inspection on 10 October 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. During this inspection we found that some areas had been addressed but that some actions had not yet been put in place; we also found some further areas of concern, which required further investigation. Therefore, the decision was made to extend the focussed inspection to a full comprehensive inspection, and we returned to the practice for an announced visit on 1 November 2016 in order to consider the areas which had not been covered during the focussed inspection and to look in further detail into the further areas of concern we had noted. This report covers our findings from both follow-up inspections on 10 October 2016 and 1 November 2016. You can read the report from the initial comprehensive inspection by selecting the ‘all reports’ link for St Margaret’s Medical Practice on our website at www.cqc.org.uk .
Overall the practice was rated as requires improvement following the initial comprehensive inspection on 27 January 2016. They were rated as requires improvement for providing safe and effective services and for being well led. Following the re- inspection we found the practice to be requires improvement for providing a safe service and good for providing an effective service and for being well led.
Our key findings were as follows:
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. During the initial inspection we found that reviews and investigations into significant events were not thorough enough and there was a lack of evidence that lessons learned were discussed and shared. During the re-inspection we saw evidence that significant events were well recorded and that they were discussed with staff at all levels as appropriate.
At the time of the initial inspection the provider had not ensured the correct legal authorisations were in place for staff to carry out their roles safely, specifically, they had not put Patient Specific Directions in place to allow their healthcare assistant to administer medicines. These were in place when we returned to the practice in November 2016.
Overall, staff assessed patients’ needs and delivered care in line with current evidence based guidance. When we initially inspected the practice we found that they did not have an effective system for recording and acting on medicines updates and safety alerts. We also found that the practice had failed to ensure that a complete and contemporaneous record was kept in respect of each service user, they did not have care plans in place for all patients who needed them, and there was a lack of evidence that the outcome of assessments of capacity to consent were recorded in patient records. When we returned for the follow-up inspection we saw evidence that the practice was appropriately recording and acting on safety alerts and that care plans were in place. However, we found evidence that in some cases consultations were still not being adequately recorded. All of the examples we saw were the responsibility of one member of staff, and we were aware that issues relating to this individual’s performance were being addressed externally.
Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. The practice had recently trained two members of staff as repeat prescribing clerks and face to face training sessions had been provided to these members of staff by one of the GPs, that covered which medicines they were allowed to issue prescriptions for; however, written guidance was not in place.
Data showed patient outcomes were below the local and national average in some areas; however, results from the Quality Outcomes Framework showed the practice’s performance had improved during the 2015/16 reporting year compared to the previous year, and the practice had introduced measures to further improve during the current reporting year.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
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.
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 practice proactively sought feedback from staff and patients, which it acted on. At the time of the initial inspection we found that the provider had failed to ensure that every member of staff had received an appraisal. During our re-inspection on 1 November 2016 we found that appraisals had been completed for all staff.
There was one area where the provider must make improvement:
They must put arrangements in place to ensure that all staff are making complete and contemporaneous records of patient consultations.
In addition, they should make improvements in the following areas:
They should ensure that written guidance in put in place for the issuing of repeat prescriptions.
They should ensure that they are regularly checking uncollected prescriptions and that arrangements are in place to contact vulnerable patients who have not collected their prescription.
They should take further action to ensure that carers are identified and supported.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Margaret’s Medical Practice on 27 January 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvements are:
In addition the provider should:
Chief Inspector of General Practice
We observed that despite being very busy on the day of our inspection, reception staff were available to assist people in a timely manner, and were professional and polite. We found that when we sat in the reception area, we could not hear what was being said as people checked in for their appointments. We also could not hear what was being said when reception staff were on the phone. If patients were uncomfortable speaking to staff in the reception area, a separate private room was available.
We found that there were appropriate infection control measures in use at the practice and that medicines were adequately managed. We also found that people were protected from the risk of abuse because procedures were in place at the practice for safeguarding children and vulnerable adults, and staff demonstrated that they were aware of these procedures.