Dr U Ota & Partners Also known as St Georges Medical Centre

Following our annual regulatory review of the information available to us, we inspected this service on 28 January 2020. The service was last inspected in April 2016. It was rated as good for providing safe, effective, caring, responsive and well led services.

The current inspection looked at the following key questions; was the service providing safe, effective, caring, responsive and well led services for the registered patient population.

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 Requires Improvement overall.

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

• The system for safety alerts did not ensure that the alert had been actioned across the whole practice.
• Management of significant events did not always address the safety issues.
• Safeguarding records were not effectively managed to best protect vulnerable people.

We rated the practice as good for providing effective services because:

• Patients received effective care and treatment that met their needs.

We rated the practice as requires improvement for providing caring services because:

• The practice scored significantly lower than average in the national GP Patient Survey in relation to patients feeling listened to and be treated with care and concern.

We rated the practice as requires improvement for providing responsive services because:

• The practice scored significantly lower than average in the national GP Patient Survey in relation to patients having access to services which met their needs.

We rated the practice as requires improvement for providing well-led services because:

• The practice failed to identify an incident as being a “notifiable safety incident” under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• There were areas where governance mechanisms were not effective for example, in safety alerts, in significant events and the management of safeguarding records
• The practice’s registration was not compliant with the provisions of the Health and Social Care Act 2008.

We have rated this practice requires improvement for all population groups because the provider has been rated as requires improvement for providing responsive services. The areas that require improvement impacted all patient population groups.

The areas where the practice should make improvements are:

• Continue to implement appropriate actions to reduce the prescribing of identified classes of antibiotics.
• Review the documentation relating to Patient Group Directive to ensure it is current and correct.
• Implement actions to improve uptake for the cervical screening programme and for child immunisations to meet the national targets.
• Continue to monitor Quality and Outcomes Framework (QOF) exception reporting and continue to implement appropriate measures to reduce this in line with local and national data
• Continue to consider the content of the National GP patient survey and take actions to mitigate the impact.
• Continue to improve the identification of carers, to ensure they receive appropriate care and support.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Act in accordance with the Duty of Candour

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