Mansion House

Updated 14 December 2018

Mansion House Surgery is registered with the Care Quality Commission (CQC) as a partnership provider and holds a General Medical Services (GMS) contract with NHS England. A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract. The practice is part of the NHS Stafford and surrounds Clinical Commissioning Group (CCG).

The practice is located within a two-storey purpose built health centre in Stone, Staffordshire. The practice treats patients of all ages and provides a range of general medical services and delivers regulated activities solely from this practice. Car parking is available at the practice. A commercial pharmacy is located within the same site.

At the time of the inspection there were approximately 14,140 patients registered at the practice. The practice local area is one of less deprivation when compared with the local and national averages. The area has similar outcomes to the local and national averages in the area profile data from Public Health England. The data compares outcomes living in the area including life expectancy and deprivation. The practice has a higher percentage of registered patients over the age of 44. The practice unemployment levels are lower than local and national averages. The practice population is predominantly white (98.6%). The practice is a teaching practice for specialist trainee doctors. At the time of the inspection there were two registrars working at the practice.

The practice staffing comprises:

• Five GP partners and one salaried GP.
• One regular GP locum.
• Two registrars.
• Three advanced nurse practitioners.
• Two Clinical prescribing pharmacists.
• Four part-time practice nurses which included the lead nurse.
• Three part-time health care assistants.
• One part-time phlebotomist.
• One practice manager and one assistant practice manager.
• A team of 12, administrative and reception staff which include a secretary.

The practice is open between 8:00am - 6:30pm Monday to Friday. Extended opening hours are provided on a Wednesday evening between 6.30pm and 8pm. The practice has increased the extended hours provision and become a member of the Primary Care Extended Access GP First initiative. The group is made up of doctors, advanced nurse practitioners and clinical prescribing pharmacists. This group work collaboratively across all practices in the Stafford and surrounds area. Appointments are booked at the patients’ usual practice but could be offered at any of the participating practices. When the practice is closed patients are directed to call NHS 111 service. Routine appointments can be booked in person, by telephone or on-line. Home visits are triaged by a clinician to assess whether a home visit is clinically necessary and the urgency for medical attention.

The provider is registered to provide the following regulated activities:

Diagnostic and screening procedures, family planning, maternity and midwifery, surgical procedures and treatment of disease, disorder or injury.

Additional information about the practice is available on their website: www.mansionhouse surgery.nhs.uk

Updated 14 December 2018

This practice is rated as Good overall. (Previous rating November 2017 – Good overall). The practice was rated as requires improvement for providing safe services. A breach of legal requirement was found and a requirement notice was served in relation to safe care and treatment. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Mansion House Surgery on our website at www.cqc.org.uk.

The key questions at this inspection 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 Mansion House Surgery on 19 November 2018. This was to follow up on breaches of regulations and confirm the practice had met the legal requirement in relation to the breach in regulation that we had previously identified.

At this inspection we found:

• The practice leaders had taken the findings from the previous CQC inspection to improve the services provided and patient safety and care. The breach in regulation had been addressed and all of the best practice recommendations we made at the previous inspection had been addressed. However, we identified further improvement was required in some areas.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had effective systems, processes and practices in place to protect people from potential abuse and staff had received safeguarding training appropriate to their role.
• There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff.
• The practice routinely reviewed the effectiveness and appropriateness of the care provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Some patients reported that they found difficulties with the appointment system use and that they found it stressful to access care when they needed it.
• The practice actively worked with the patient participation group (PPG) to meet the needs of their patients and were also working towards developing a virtual PPG.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to develop root cause analysis to provide sufficient detail when investigation incidents and complaints.

• Complete the ongoing development for a written vision and strategy for the service.
• Consider the electronic sign in screen having more than one language.
• Take appropriate action to improve the telephone access for patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Updated 14 December 2018

Updated 14 December 2018

Updated 14 December 2018

Updated 14 December 2018

Updated 14 December 2018

Updated 14 December 2018