We carried out a review of the data available to us about St Clements Surgery 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 Clements Surgery, you can give feedback on this service.
This practice is rated as good overall. (Previous rating February 2018 – Requires improvement)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at St Clements Surgery over two days in February 2018 and March 2018 as part of our inspection programme where the surgery was rated as requires improvement overall. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements. The full comprehensive report of all previous inspections can be found by selecting the ‘all reports’ link for St Clements Surgery on our website at
This inspection was an announced comprehensive inspection carried out on 26 November 2018 to check whether the providers had taken action to meet the legal requirement’s’ as set out in the requirement notices. The report covers our findings in relation to all five key questions and six population groups.
At this inspection we found:
The areas where the provider should make improvements are:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
This practice is rated as Requires improvement overall. (Previous inspection October 2015 – Good)
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires Improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those recently retired and students – Requires Improvement
People whose circumstances may make them vulnerable – Requires Improvement
People experiencing poor mental health (including people with dementia) - Requires Improvement
At this inspection we found:
The practice had systems in place to manage risk so that safety incidents were less likely to happen. Records viewed during our inspection, showed that when incidents did happen, the practice learned from most of them and were able to demonstrate improvements made to reduce recurrence.
The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. However, monitoring of actions aimed at improving quality and effectiveness in some areas of medicines management was not effective.
Results from the July 2017 annual national GP patient survey showed patients felt they were treated with compassion, dignity and respect. Completed Care Quality Commission comment cards were mainly in line with the results.
Patients did not always find the appointment system easy to use and found they were not always able to access care when they needed it. The practice was aware of the issues and taking action to improve access.
The leadership, governance and culture were used to drive and improve the delivery of its service. All staff were involved in the development of the practice. However, we found some systems and processes were not embedded to ensure compliance with practice policies and procedures. For example, oversight of recruitment checks, training, significant events and complaints was not effectively managed.
The areas where the provider must make improvements are
Ensure care and treatment is provided in a safe way to patients
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
Ensure effective monitoring of training needs so that persons employed in the provision of the regulated activity receive appropriate training necessary to enable them to carry out the duties.
Ensure incident reports and complaints clearly demonstrate details of investigations and actions taken to remedy the situation and prevent further occurrences.
Ensure medication reviews are carried out with patients in receipt of interventions for substance and alcohol dependency and continue to improve communication with community teams to ensure safer monitoring of patients treated in the community.
Continue exploring measures to improve the uptake of cervical, breast and bowel screening as well as childhood immunisations.
Continue establishing methods to improve patient satisfaction in areas identified from survey results and patient feedback.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Clements Surgery on 16 October 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
We saw an area of outstanding practice:
Staff understanding and vigilance in safeguarding had led to the successful protection of several vulnerable patients. The practice reflected on such events to identify whether there was anything they could have done differently or better. A safeguarding audit was undertaken to ensure staff knowledge in order to protect patients resulting in increased staff confidence in raising concerns. Key staff had received training in female genital mutilation (FGM) so that they were aware and vigilant of the risks and was relevant to the population served.
The practice was very proactive and flexible in the way in which services were delivered which helped ensure all patients could access care and support and were encouraged to do so. There were numerous examples including: the translation of information on childhood immunisations to encourage uptake from the Somalian population; the identification of women who would benefit from more frequent cervical screening, home visits for carers who could not leave the person they were caring for and open appointments for walk in patients.
The areas where the provider should make improvement are:
Maintain records to demonstrate and provide assurance that emergency equipment such as oxygen and defibrillator have been checked and are in good working order.
Chief Inspector of General Practice