St Mary's Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Mary’s Medical Centre on 25 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 25 July 2016 inspection can be found by selecting the ‘all reports’ link St Mary’s Medical Centre on our website at www.cqc.org.uk. At that inspection the practice did not have effective systems to manage the following:

• Legionella and fire safety risk assessments had not been completed.

• Complaints were not managed effectively.

• The quality of the service was not managed for the purpose of making improvements.

• Staff training was not monitored.

• The provider did not have a system to follow when a Disclosure and Barring Service (DBS) check was received provided negative information about potential employees.

• Practice specific policies were not in place for the prevention and control of infection.

• The provider did not have procedures in place to monitor all blank prescriptions, including those in printers.

Within an agreed timescale the practice submitted an action plan which demonstrated they are now meeting the requirement notices from this inspection.

We carried out this announced follow up comprehensive inspection at St Mary’s Medical Practice on 10 August 2017 to ensure the issues identified at the previous inspection had been met. The practice had addressed the breaches of regulation and was now compliant with all regulations. This report covers our findings in relation to those improvements and also additional findings at this inspection. Overall the practice is now rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. For example, fire safety and the prevention of legionella.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Staff were provided with relevant training which was monitored to ensure they kept up to date with changing care practices and new ways of working.

• The provider had a system to follow when a Disclosure and Barring Service (DBS) check was received which provided negative information about potential employees.

• Practice specific policies were in place for the prevention and control of infection.

• The provider had procedures in place to monitor all blank prescriptions, including those in printers.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Patient care plans should be streamlined to ensure the copy recorded on the practice IT system was the same as the copy given to the patient.

• The practice nurse induction programme should be developed to outline staffs role and responsibilities.

• The information given to patients about how to make a complaint should include details of the ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice