We carried out a review of the data available to us about St Paul's Cottage Surgery 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 St Paul's Cottage Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at St Paul’s Cottage Surgery on 19 October 2016. The overall rating for the practice was good; however the safe domain was rated as requires improvement as:
Systems, processes and practices to keep patients safe were not always effective with regards to prescription security and checks for emergency equipment.
We also asked the practice to:
Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for St Paul’s Cottage Surgery on our website at www.cqc.org.uk.
This inspection was a desk-based review carried out on 16 May 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 19 October 2016. This report covers our findings in relation to those requirements and also any additional improvements made since our last inspection.
Overall the practice maintains a rating of good, with the safe domain now also rated as good.
Our key findings were as follows:
The practice had reviewed and updated their prescription security protocol to reflect improvements made.
The practice had installed key code locks on all clinical room doors, ensuring security of blank prescriptions when rooms were not occupied.
The practice maintained a record of prescription use through a log of serial numbers of prescriptions delivered to the practice and a record of when those prescriptions were issued and used.
Emergency equipment was checked appropriately and regularly by and these checks were recorded and reviewed.
The practice had also reviewed how patients with caring responsibilities were identified and recorded on the clinical system to ensure information, advice and support was made available to them. The practice strategy included new and existing patients:
The practice ran a campaign to identify and offer information, advice and support to carers in the practice population. This campaign included posters in the waiting area and clinical areas, discussions with individual patients and including carer identification on the practice registration form for new patients. The campaign to date has identified 29 new carers.
All carers are written to and offered advice and information as well as a structured health and social care review with a clinician. In 2016/17, 44% of carers took up the offer of an annual health and social care review.
The campaign has also resulted in 32 patients who were previously identified as carers being voluntarily removed from the register as they no longer provide caring responsibilities. This meant the practice could target carer support and information directly to those who needed it.
The practice currently has 61 carers on their register (0.8% of the practice population).
The areas where the provider should make improvement are:
Continue to monitor and review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Paul’s Cottage Surgery on 19 October 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
Systems, processes and practices to keep patients safe were not always effective with regards to prescription security and checks for emergency equipment.
We saw one area of outstanding practice:
The practice identified lower uptake for the cervical screening programme amongst particular patient groups, in particular Asian women. In response they engaged a local Asian women’s support group and set up their own practice group for Asian women, led by a female GP who spoke Urdu and the practice nurse. Asian women on the practice list were contacted and invited to attend an event to learn about the services offered at the practice including how to make appointments, to discuss healthy lifestyles, diet and exercise as well as national screening programmes for breast, bowel and cervical cancers. The event also included information on stress, domestic violence and abuse. Information was provided in English and Urdu and the women had the opportunity to ask questions and seek advice in the group and privately. Six patients attended the group session and directly following the practice engagement event, two of the patients booked appointments for their cervical screening. We spoke to a representative of the practice’s Asian women’s group who told us how important the event was to the people who attended and the wider community in sharing information and removing barriers to care.
The areas where the provider must make improvement are:
Review and improve systems and processes for checking emergency equipment and maintaining prescription security.
The areas where the provider should make improvement are:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice