Merchiston Surgery

We carried out an announced inspection at Merchiston Surgery on 15 June 2022. Overall, the practice is rated as Requires Improvement.

We have rated each key question as:

Safe - Requires Improvement

Effective - Requires Improvement

Caring - Good

Responsive - Requires Improvement

Well-led - Requires Improvement

The provider of this service changed since our previous inspection on 11 June 2018. The service was rated Good overall and for all key questions. Consequently, this inspection is the first under the new provider, Wyvern Health Partnership, since registration on 21 December 2020.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Merchiston Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive risk based inspection undertaking a site visit and remote clinical searches to review:

• Safe, Effective, Caring, Responsive, Well-led domains
• Risks identified in relation to patient access through complaints to CQC.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• A presentation from the provider

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall

We found that:

• The practice provided care that did not always keep patients safe.
• Patients did not always receive effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could not access care and treatment in a timely way.
• Governance processes were in place but oversight of risk management to patient safety and providing effective services was not always fully embedded.

We found breaches of regulations. The provider must:

• Care and treatment must be provided in a safe way for service users.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are employed.

The provider should also:

• Improve the uptake of cervical cancer screening to eligible patients.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care