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Inspection Summary

Overall summary & rating


Updated 8 November 2018

This practice is rated as Good overall. (Previous rating May 2018 – Good)

The key questions at this inspection are rated as:

Are services well-led? - Good

We carried out an announced focused inspection at St Peters Hill Surgery on 2nd October 2018. The practice had previously been rated as good overall in May 2018. However were rated as requires improvement in delivering well-led services. This inspection was to investigate whether the governance systems had been implemented to improve systems for complaints, infection control, staff training and monitoring of refrigerator temperatures.

At this inspection we found:

  • The practice had reviewed and taken action on the report published in May 2018 and implemented systems and processes to improve the practice performance.
  • The system for complaints and significant events ensured that incidents were investigated and reported on in a timely matter. We saw that staff members were involved with the process and the practice understood the duty of candour where appropriate.
  • The practice had a system to manage infection prevention and control and had implemented a new cleaning schedule for all areas of the practice.
  • The management of staff records and training was well managed and alerted staff when training was due to be completed.
  • Refrigerators temperatures were monitored twice daily and secondary thermometers were in use.

The areas where the provider should make improvements are:

  • The provider should hold an immunisation record for staff.
  • Ensure that back up thermometers provide accurate information.
  • Continue developing the meeting schedule within the practice and providing accurate meeting minutes.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas











Updated 8 November 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • We saw evidence of the managers and leader’s discussions about the practice stability and succession plans.
  • Practice staff reported leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice management liaised with other practices through a GP improvement scheme.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.


The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued as team members. They were proud to work in the practice.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values from staff or patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour. We saw evidence of the practice responding to complaints in a timely manner.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed. Staff told us they would be involved in the investigation process if required and could access all information regarding incidents on the internal shared document system.
  • There were processes for providing all staff with the development they need. The practices previous inspection in October 2017 identified that the practice needed to improve their system for appraisals. We looked into appraisals during this inspection and found that staff had received annual appraisals with two members of staff currently awaiting booked appraisals. Staff informed us that their appraisals included career development conversations.
  • We asked to look at the validation status of all clinical staff which was recorded on a tracking system to highlight when revalidation was due. Practice management supported staff to meet requirements where necessary.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • The practices October 2017 inspection identified that the process from infection control was not effective. The lead for infection control had since completed training courses and implemented a new infection control policy and audit. We saw evidence that an action plan had been completed and the practice were working through the action plan in the agreed timescales. The practice had also implemented a cleaning schedule for the contracted cleaners. The infection control lead completed monthly spot check audits of different rooms to ensure that the cleaning schedules had been completed.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. On the day of the inspection the practice were in the process of reviewing all policies and making them available on the computer system they had implemented for all staff to have instant access to.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. The practice held regular meetings to discuss the future of the practice.
  • Practice leaders had oversight of safety alerts, incidents, and complaints. We saw evidence that these were discussed during manager meetings and information was disseminated to the wider staff team.
  • The practice had implemented a process for recording temperatures of fridges which contained medicines. We saw evidence these fridges were recorded twice a day. Staff knew what to do if the fridge went out of range. The practice had also put secondary thermometers in the fridge. However they were in the process of changing them due to the download of data not always working.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. The practice was involved with the CCG to implement any requirements.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care. We saw evidence of the practice using templates on the clinical system to ensure prescribing was in line with national and local guidance. The practice monitored prescribing on an ongoing basis.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Following the practices previous inspection in October 2017, the practice had implemented a system for significant events and complaints. We saw all incidents and complaints were investigated and reported in a timely manner. We saw the practice responded promptly to complainants and included apologies if necessary. Complaints and significant events were available to all staff during team meetings or the document sharing system for the practice.
  • We asked to look at recruitment files for staff on our inspection and found that management had organised the staff files into sections and documents which were required were there. However, there was no immunisation status for staff on the day of the inspection. The practice informed us they would be putting it on the computer system when available along with any flu vaccination status in the future.
  • Staff training had been identified during the October 2017 inspection and we saw that improvement had been made during this inspection. The practice management had an overview of training and could see in advance any which were going to expire. The practice were in the process of moving over from face to face training sessions to ensuring staff completed online training necessary for their role.
  • The practice had implemented a meeting schedule for team meetings, clinical meetings and informal doctor’s meetings. Since their previous inspection, the practice produced formal minutes for meetings however felt that this was not required for the informal daily doctor’s meetings. The practice had implemented a new system for capturing what was discussed. The minutes from other meetings were available to staff who could not attend.
  • The practice had regular full team meetings to discuss a set agenda including any upcoming changes. The practice then provided regular protected learning time for individuals to complete mandatory training or to work towards any objectives which had been identified during the staff appraisals.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions


Updated 4 May 2018

The practice is rated as good for the care of people with long term conditions.

  • Clinical staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. Where patients had more than one condition, reviews were combined to avoid multiple appointments for patients.
  • For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • Blood tests were available throughout the day as a staff member took samples to the hospital if it was after the pathology collection had taken place earlier in the day.
  • Blood tests and long term condition reviews were available on Saturday mornings.
  • The practice funded the loan of home blood pressure monitors to patients and had around 250 machines available.
  • The community diabetic nursing team ran clinics from the practice.

Families, children and young people


Updated 4 May 2018

The practice is rated as good for the care of families, children and young people.

  • From the examples we reviewed we found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances or had not been taken to hospital appointments.
  • Immunisation rates were high for all standard childhood immunisations.
  • Children and young people were treated in an age-appropriate way and were recognised as individuals.
  • Appointments were available outside of school hours.

The practice worked with midwives, health visitors and school nurses to support this population group.

  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.
  • There were daily appointments available with specialist minor illness nurses for a variety of acute problems for children over the age of two years.

  • Meetings took place between GPs and associated health care professionals to discuss children with a safeguarding concern.
  • Asthma clinics were available after school or on Saturday mornings for school age children.
  • Baby changing facilities were available.

Older people


Updated 4 May 2018

The practice is rated as good for the care of older people.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.
  • The practice offered home visits and urgent appointments for those with enhanced needs.
  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

  • Care plans were in place for patients at high risk of hospital admission on the frailty register and these patients were proactively managed by the practice care coordinator to avoid hospital admissions.
  • The practice care coordinator had held ‘family days’ at local nursing homes to provide information and assistance to relatives.
  • The practice offered midweek morning flu clinics for elderly patients who did not want to attend on a Saturday or in an evening.
  • Practice staff had delivered medication to patients on the frailty register on their way home, when pharmacy deliveries had finished for the day.

Working age people (including those recently retired and students)


Updated 4 May 2018

The practice is rated as good for the care of working age people (including those recently retired and students).

The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours and telephone consultations. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.

  • The practice undertook pre university and occupational vaccinations and reports as required.
  • The practice were supportive of students when ‘back at home’ to enable them to access health care.
  • The practice was open on Saturday mornings with both GP’s and nursing staff available.
  • There were appointments available on a daily basis with minor illness nurses.
  • Blood tests were available all day every day including during extended hours.
  • As a result of patient feedback, more evening appointments were made available for smear tests and chronic disease reviews.

People experiencing poor mental health (including people with dementia)


Updated 4 May 2018

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • Patients were able to self-refer to the Improving Access to Psychological Therapies (IAPT) service without seeing a GP.

  • 79% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was below the national average of 84%.
  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
  • Immediate access to a GP or nurse was available for patients with urgent mental health needs.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment.
  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
  • A number of staff members had trained as ‘Dementia Friends’ to enable them to better support patients with dementia.
  • Community psychiatric nurses were able to use a room at the practice to meet with patients who were more comfortable meeting there than elsewhere.

People whose circumstances may make them vulnerable


Updated 4 May 2018

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability. Travellers regularly registered as temporary residents.
  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice offered longer appointments for patients with a learning disability and worked with a local care home for patients with a learning disability to ensure appointments were convenient to them and visited the home to carry out reviews where necessary.
  • The practice regularly worked with other health care professionals and other agencies in the case management of vulnerable patients.
  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations and told us they had offered support to homeless or vulnerable patients in order to enable them to travel to a shelter or hospital.
  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • The practice was a food bank voucher distributor.