Suttons Medical Group had been inspected previously on the following dates: -
25 and 26 July 2017 under the comprehensive inspection programme. The practice was rated as Requires Improvement overall with Requires Improvement for providing a safe and well-led service. A breach of legal requirements was found in relation to Safe care and treatment, Safeguarding service users from abuse and improper treatment and Good Governance. Requirement notices were issued which required them to submit an action plan on how they were going to meet these requirements.
12 July 2018 we carried out a comprehensive inspection and to follow up on breaches of regulations identified at our inspection in July 2017. At this inspection the practice was rated as Good overall with a Requires Improvement for providing a well-led service. The practice had made a number of improvements but further work was required to ensure that the systems and processes the provider had in place were established and operated effectively.
We carried out an announced focussed inspection at Suttons Medical Group on 17 July 2019 as part of our inspection programme. Following the Care Quality Commission annual regulatory review, we inspected the domain area of well led and utilised information from our previous inspection findings for the domain area of well-led.
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
This practice is rated as Good overall with a good for providing well-led services.
- We found that the practice had improved the cascade of information sharing for all significant events, complaints , dispensing errors and near misses reported and these were shared with the practice team to ensure learning is identified and actions were taken to reduce the risk of further incidents happening.
- Patients were offered translation services if required.
- Dispensary standard operating procedures had been reviewed and updated to contain relevant information.
- Since the last inspection the practice had carried out further quality improvement audits to demonstrate improvements and the impact for patients.
- We looked at the 2019 GP patient survey figures which had been released on 12 July 2019. We found the practice had improved in 15 out of the 18 questions against the CCG and national average.
- At this inspection we saw that the practice had recently carried out an inhouse patient survey. We saw a well-documented review of findings.
- At this inspection we also looked at the data for 2018/19 QOF. We saw that the practice had again achieved 100% but this data was unverified at the time of the inspection. Exception rates were not available but from a review of the disease registers we could see that the practice had high prevalence in a number of disease areas and how much hard work had been carried out by the teams to achieve 100%.
The areas where the provider should make improvements are:
- Improve the recording for significant events and ensure all meetings held have minutes that contain details of the discussions, learning and actions taken.
- Ensure the audit trail for sharing, learning and actions required for patient safety alerts is improved and embedded within the practice.
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