Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Peters Surgery on 29 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for St Peters Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on12 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 29 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
- The practice was able to demonstrate that the system for reporting, recording and learning from significant events was consistently and effectively implemented
- Medicines management procedures had been reviewed to ensure an effective process for managing medicine alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
- Blank prescription forms and pads were securely stored with a system to monitor their use.
- Risk assessments and management activities included all potential and actual risks to patients, staff and visitors and recommendations and actions were implemented in a timely manner.
- Recruitment checks were carried out for all members of staff including locum GPs.
- Staff received appropriate support through regular appraisals.
- Staff received ongoing training appropriate to their role including fire safety training.
- There were systems to help ensure the safety of services. For example, the recording of fire evacuation rehearsal procedures and the checking of emergency equipment.
- The practice had a system to monitor and record the hepatitis B status of GPs and nurses.
- The practice was not based in a purpose built building. However, the entrance doorways were wheelchair accessible, the doors opened inwards when pushed and there was a bell to attract the attention of reception staff.
- The practice had identified an increased number of patients as carers. There were 80 patients on the carers register, almost 2% of the patient list.
- Information regarding how to make a complaint was displayed in the patient waiting area.
- The practice were aware of patients waiting 15 minutes or less for their appointments. They responded by routinely asking patients to telephone before their appointments in order to ascertain waiting times at the practice and had an action plan to audit appointments. Conversely, 96% of respondents to the GP patient survey published July 2017 found that their GP appointment provided enough time, compared to 86% at CCG and national average. 95% of respondents were able to make an appointment with their preferred GP compared to the CCG average of 64% and the national average of 56%.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice