Background to this inspection
Updated
11 August 2021
Vista Road Surgery is provided by Market Street Surgery and is situated at
Vista Road,
Newton-Le-Willows,
Merseyside.
WA12 9ED.
There is also a branch surgery
Kinnock Park surgery
Buttonwood,
Warrington,
Cheshire,
WA5 4PU.
The practice is part of the St Helens Clinical Commissioning Group (CCG) and has a General Medical Services (GMS) contract and out of hours services are provided by St Helens Rota. The provider offers a range of general practice services to the whole population.
The practice has a register of 7,893 and the proportion of people over 65 years is higher than the local and national averages.
The practice is registered with the Care Quality Commission to provide:
- Maternity and midwifery services
- Diagnostic and screening services
- Surgical procedures
- Treatment of disease, disorder or injury
The practice is open Monday to Friday 8am to 6.30pm.
The management team consists of the practice manager; office manager and four GP partners.
The clinical staff consists of:
Five GPs (three males and two female)
One advanced nurse practitioner (female)
One practice nurse (female)
One health care assistant (female)
The practice is also supported by a team of reception and administration staff.
The practice is designated as a teaching practice by the local university and has the responsibility for educating trainee GPs. This means that there are also GP registrars on placement in the practice.
Information published by Public Health England, rates the level of deprivation within the practice population group as three, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. People living in more deprived areas tend to have greater need for health services. Male life expectancy is 76 years compared to the national average of 79 years. Female life expectancy is 80 years compared to the national average of 83 years.
Updated
11 August 2021
At our previous follow-up inspection of the safe domain for Vista Road Surgery on 12 December 2019, the practice was rated requires improvement. On 8 July 2021 we carried out an announced desktop review of The Vista Road Surgery to assess compliance with the breaches found at that time and we have rated the safe domain as good
Overall, the practice remained rated as Good.
The rating for the key question followed up was:
Safe - Good
The other key questions remain unchanged and are rated as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Vista Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focussed review of information we hold and did not involve a site visit. This was to follow up on the key question – Are the services at this location Safe.
We reviewed the breaches identified at the last inspection of Regulation 12 HSCA (RA) Regulations 2014 Safe Care and treatment. The regulation was not being met because:
- The provider had not identified the need to act to make sure the hot water system was cleaned and chlorinated in line with the recommendations from the legionella report completed December 2018.
- The provider had not ensured guidance and systems for handling letters from secondary services were clear or put a failsafe in place to ensure these were always dealt with appropriately.
- The provider did not have effective arrangements in place for the monitoring and security of prescriptions pads and computer prescription paper, both on delivery and when they were distributed through the practice.
- The provider had not completed a risk assessment to identify mitigating steps needed regarding medicines or other items omitted from the emergency medicines and equipment kit.
- The provider had not ensured all equipment provided for emergency response is clean and fit for purpose
- The provider had not ensured documents that gave nurses permission to administer prescription-only medicines were completed properly and legally.
We reviewed breaches identified at the last inspection of Regulations 19 HSCA (RA) Regulations 2014 Fit and proper persons employed. The regulation was not being met because:
- Disclosure and barring checks (DBS) had not been completed for recently employed staff.
- A risk assessment had not been completed to identify and mitigate potential risks.
- Systems were not in place to support the completion of these checks before staff took up their posts.
- A health declaration which confirmed fitness for the role had not been sought from the most recent recruit.
- Information to confirm the immunisation status of staff was not readily available.
- Systems were not in place to support the completion of these checks before staff took up their posts.
We also reviewed the areas where we recommended that the provider should make improvements:
- Consider measures to prevent accidental power loss to the vaccination fridge that is not hard wired.
- Consider displaying the cleaning rota in each room. Review the cleaning schedule for the consultation room used for minor surgery room.
How we carried out the review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.
This review was carried out without visiting the practice. 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
- Requesting evidence from the provider
- Reviewing action plans sent to us by the provider
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found from the documents the practice submitted and from our interviews with staff
- 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 Good overall and Good for all population groups.
We found from the documents submitted that:
The breaches of regulation 12 HSCA had been addressed:
- Action had been taken to ensure the hot water system was safe and complied with all legionella water safety requirements;
- prescription pads were stored securely;
- the contents of emergency response kits had been risk assessed;
- we saw records that showed the emergency response medicines and equipment were clean and well maintained;
- non-medical prescribers were correctly authorised to administer prescription only medicines legally;
- systems had been introduced to ensure letters from secondary care were dealt with efficiently and actioned as required.
The breach of regulation 19 HSCA (RA) had been addressed to ensure that all the information specified in Schedule 3 HSCA was readily available for each person employed. Evidence of pre-employment health checks and ongoing checks of professional registration were provided.
We found that the provider responded to the ‘shoulds’ that were identified at the previous inspection.
- The provider had taken effective steps to prevent accidental power loss to the vaccination fridge as it had now been hardwired in order to prevent accidental switch-off.
- The provider had ensured cleaning rotas were placed in all rooms. These were monitored to ensure the cleaning regimes were followed.
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