Staverton Surgery

We carried out an announced focused inspection at Staverton Surgery, with the remote clinical review on 20 September 2021 and site visit on 22 September 2021. Overall, the practice is rated as good.

Safe – Requires improvement

Effective – Good

Caring – Not inspected

Responsive – Not inspected

Well-led – Good

Following our previous inspection on 9 January 2020, the practice was rated requires improvement overall and specifically requires improvement for the key questions whether the practice is providing safe and effective care. We undertook this inspection to follow up the concerns from the last inspection. We did not inspect the key questions whether the practice is providing caring or responsive care on this occasion.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Staverton Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a focused inspection to follow up on whether:

• Care and treatment was being provided in a safe way to patients.
• There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.
• There were sufficient numbers of suitably qualitied, competent, skilled and experienced persons were deployed to meet the fundamental standards of care and treatment.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. 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.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

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.

We have rated this practice as good overall. The population groups have been rated as requires improvement for working age people (including those recently retired and students). We have rated the practice as good for older people, people with long term conditions, families, children and young people, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

We have rated this practice as requires improvement for providing safe services because:

• We found that the staff immunisation programme was not implemented as per Public Health England (PHE) guidelines.
• We identified gaps in the training records of staff members, in particular in relation to safeguarding adults at risk, safeguarding children and Mental Capacity Act training.
• Our clinical searches identified some patients on high-risk medicines with overdue monitoring.
• We found that medication reviews, frailty reviews and care plans had been completed appropriately.
• The practice had made improvements in relation to its infection prevention and control procedures and this was being managed effectively.
• The premises were well managed and there were effective systems for managing staff and training records.

We have rated this practice as good for providing effective services because:

• The practice had resolved the issue raised at the last inspection and now ensured that there were effective processes for keeping clinicians up to date with current evidence-based practice.
• The practice’s uptake for cervical screening remained markedly lower than the 80% coverage target for the national screening programme. We did not see sufficient action by the practice to understand this low uptake or to address effectively any barriers to the uptake of screening.

We have rated the practice as good for providing well-led services because:

• We identified some shortfalls in overall governance and risk management systems detailed above. The systems for oversight of staff training and staff immunisations were not in line with Public Health England guidelines.
• Governance structures were in place to support the management of the practice.
• Actions were taken to support the maintenance of the service during the Covid-19 pandemic.
• We received feedback from the Patient Participation Group that the practice was open and honest and that the practice had worked hard to engage with the patient population groups.
• Staff spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

In addition to the above, the practice should:

• Continue to review and monitor patients with long-term conditions, including pre-diabetes and asthma.
• Monitor patients on high risk medicines in line with clinical guidance.
• Demonstrate an understanding of why childhood immunisations uptake is low and what barriers there are to uptake in patient population, and take action to address such barriers as appropriate.
• Keep necessary documentation on staff files.
• Keep documents on practice processes.
• Review and risk assess the arrangements for the evacuation of patients with mobility issues.

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