Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. We previously inspected the service on 25 March 2015 and rated the service Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Mansion House on 1 November 2017 as part of our inspection programme.

At this inspection we found:

• The practice had systems, processes and practices in place to protect people from potential abuse. Staff were aware of how to raise a safeguarding concern and had access to internal leads and contacts for external safeguarding agencies. However, not all staff had received up-to-date safeguarding training relevant to their role.

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• There were systems in place for identifying, assessing and mitigating most risks to the health and safety of patients and staff. However, not all environmental risks to patients and staff had been formally assessed.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

• The partners had reviewed and increased its workforce and employed additional clinicians with a varied skill mix to help meet the health and social needs of patients and the demand for access to appointments.

• Not all staff had received essential training to enable them to carry out their duties safely.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Some patients found it difficult to make an appointment by telephone and told us appointments with GPs did not always run on time.

• The practice had extended its facilities and was well equipped and maintained to treat patients and meet their needs.

• The practice worked proactively with the patient participation group (PPG) to meet the needs of their patients and had consulted with them and members of the community before the building work on the recent extension began and the PPG officially opened the new building.

• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients. In particular: carry out risk assessments to identify and assess all environmental risks to patients and staff and identify the emergency medicines that are not suitable for the practice to stock. Ensure staff receive up-to-date essential training to include safe working practices and safeguarding.

The areas where the provider should make improvements are:

• Ensure information about how to make a complaint is easily available for people to access.

• Ensure policies and procedures that govern activity are reviewed and updated to reflect practice.

• Review the monitoring of uncollected prescriptions in line with the practice policy.

• Consider more structured and on-going review of the advanced nurse practitioner and clinical prescribing pharmacist competency to support them in their evolving role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We inspected this service on 25 March 2015 as part of our new comprehensive inspection programme.

The overall rating for this service is good. We found the practice to be good in the safe, effective, caring, responsive and well-led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health.

Our key findings 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, but not necessarily with their preferred GP, and urgent appointments were available the same day either with a GP or Nurse.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Patients identified as having severe mental health needs were offered an annual review with the practice nurse and the community psychiatric nurse at the practice, so both their physical and mental health needs could be reviewed during one appointment.
• 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.

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

The provider should:

• Ensure there is a system in place to discuss and review actions for significant events on a regular basis.
• Strengthen the infection prevention and control processes.
• Carry out risk assessments to manage and monitor the risks to patients, staff and visitors.
• Introduce a system to ensure the checks on patients' abnormal results are followed through.
• Ensure all staff understand the Mental Capacity Act 2005 and implications for their practice.
• Ensure there is a system in place to review complaints for any trends or themes.
• Ensure policies and procedures are regularly reviewed and updated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating November 2017 – Good overall). The practice was rated as requires improvement for providing safe services. A breach of legal requirement was found and a requirement notice was served in relation to safe care and treatment. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Mansion House Surgery on our website at www.cqc.org.uk.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Mansion House Surgery on 19 November 2018. This was to follow up on breaches of regulations and confirm the practice had met the legal requirement in relation to the breach in regulation that we had previously identified.

At this inspection we found:

• The practice leaders had taken the findings from the previous CQC inspection to improve the services provided and patient safety and care. The breach in regulation had been addressed and all of the best practice recommendations we made at the previous inspection had been addressed. However, we identified further improvement was required in some areas.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had effective systems, processes and practices in place to protect people from potential abuse and staff had received safeguarding training appropriate to their role.
• There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff.
• The practice routinely reviewed the effectiveness and appropriateness of the care provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Some patients reported that they found difficulties with the appointment system use and that they found it stressful to access care when they needed it.
• The practice actively worked with the patient participation group (PPG) to meet the needs of their patients and were also working towards developing a virtual PPG.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to develop root cause analysis to provide sufficient detail when investigation incidents and complaints.

• Complete the ongoing development for a written vision and strategy for the service.
• Consider the electronic sign in screen having more than one language.
• Take appropriate action to improve the telephone access for patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.