Plas Meddyg Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Plas Meddyg Surgery on 11 August 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a number of policies and procedures to govern activity, which were reviewed annually. The practice held regular governance meetings where issues were discussed.
• 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.

• Some risks to patients were assessed and well managed, with the exception of those relating to medicines management, recruitment checks and responding to emergencies. Action points were not always monitored effectively to demonstrate that improvements in the practice had been successful.
• Data showed patient outcomes were average or above for the locality. Although some audits had been carried out with improvement in patient outcomes, they did not all demonstrate that any improvements had been monitored.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure that the practice has systems in place to be able to appropriately respond to emergencies, including access to a defibrillator.
• Ensure appropriate medicines management procedures are followed to include adequate monitoring of emergency medicines, oxygen, nitrous oxide and vaccine refrigerator temperatures.
• Ensure there are adequate infection control processes in place to include formalised infection control training for staff and an up to date legionella risk assessment.

In addition the provider should:

• Ensure adequate recruitment checks are carried out including criminal records checking prior to commencing employment and that comprehensive records of recruitment checks are kept.
• Ensure staff attend the scheduled child protection training so they are trained to the appropriate level.
• Ensure that there are systems in place to monitor actions taken as a result of learning and improvements from incidents and complaints, to demonstrate that changes in the practice have been successful.

• Ensure that all clinical audits undertaken show completed audit cycles to demonstrate that improvements to patient outcomes have been maintained.
• Ensure that multidisciplinary and clinical meetings are documented to demonstrate learning points, actions taken and changes to patient outcomes.
• Ensure access to services has been considered for patients with language barriers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice