We carried out a review of the data available to us about Mansion House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Mansion House, you can give feedback on this service.
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 areas where the provider should make improvements are:
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
This practice is rated as Good overall. We previously inspected the service on 25 March 2015 and rated the service Good overall.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students) – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Mansion House on 1 November 2017 as part of our inspection programme.
At this inspection we found:
The practice had systems, processes and practices in place to protect people from potential abuse. Staff were aware of how to raise a safeguarding concern and had access to internal leads and contacts for external safeguarding agencies. However, not all staff had received up-to-date safeguarding training relevant to their role.
The practice had 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.
There were systems in place for identifying, assessing and mitigating most risks to the health and safety of patients and staff. However, not all environmental risks to patients and staff had been formally assessed.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
The partners had reviewed and increased its workforce and employed additional clinicians with a varied skill mix to help meet the health and social needs of patients and the demand for access to appointments.
Not all staff had received essential training to enable them to carry out their duties safely.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Some patients found it difficult to make an appointment by telephone and told us appointments with GPs did not always run on time.
The practice had extended its facilities and was well equipped and maintained to treat patients and meet their needs.
The practice worked proactively with the patient participation group (PPG) to meet the needs of their patients and had consulted with them and members of the community before the building work on the recent extension began and the PPG officially opened the new building.
There was a focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider must make improvements as they are in breach of regulations are:
Ensure care and treatment is provided in a safe way to patients. In particular: carry out risk assessments to identify and assess all environmental risks to patients and staff and identify the emergency medicines that are not suitable for the practice to stock. Ensure staff receive up-to-date essential training to include safe working practices and safeguarding.
The areas where the provider should make improvements are:
Ensure information about how to make a complaint is easily available for people to access.
Ensure policies and procedures that govern activity are reviewed and updated to reflect practice.
Review the monitoring of uncollected prescriptions in line with the practice policy.
Consider more structured and on-going review of the advanced nurse practitioner and clinical prescribing pharmacist competency to support them in their evolving role.
Chief Inspector of General Practice
We inspected this service on 25 March 2015 as part of our new comprehensive inspection programme.
The overall rating for this service is good. We found the practice to be good in the safe, effective, caring, responsive and well-led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health.
Our key findings were as follows:
However, there were also areas of practice where the provider needs to make improvements.
The provider should:
Chief Inspector of General Practice