Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mere Surgery on 23 February 2016. Overall the practice is rated as good.

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

• There was a system in place for reporting and recording significant events.

• When there were safety incidents, patients received reasonable support, truthful information, a verbal and written apology.

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when there were safety incidents, reviews and investigations were not always recorded and lessons learned were not communicated widely enough to support improvement.

• The practice had not carried out a fire drill for at least two years.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Feedback from patients was strongly positive. This was in line with the results from patient’s satisfaction survey which were consistently and significantly higher than the national average.

• Patients said they found it easy to make an appointment with a named GP and that 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 provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

• The provider must improve the security of blank prescription forms and improve the robustness of the stock control processes.

• The provider must improve the system for informing those involved in significant events, complaints and incident reports of the outcome of investigations and ensuring learning points are adequately shared with staff.

• Ensure all Patient Group Directions are appropriately signed by the authorising clinician and the nurses acting on them.

• Ensure their complaints policy is easily accessible to all staff   and information about how to complain is easily available to patients.

• Ensure all clinical staff have an appropriate level of knowledge of the Mental Capacity Act.

The areas where the provider should make improvement are:

• The provider should carry out a risk assessment on the security of the building to include reference to the dispensary and patient files and take reasonable action to mitigate risks identified.

• Ensure the medicines management policy, including the cold chain policy, is easily available to all clinical and dispensary staff and that staff have the knowledge and skill to carry out duties relevant to their position.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

When we visited Mere Surgery on 23 February 2016 to carry out a

comprehensive inspection, we found the practice had breached regulations

relating to safe care and treatment, receiving and acting on complaints, good

governance and staffing. The practice was rated as requires improvement for

safe, effective, responsive and well-led, and good for caring. Overall the

practice was rated as requires improvement.

Following the inspection, the provider sent us an action plan

that set out the actions they would take to meet the breached regulations.

This focused desk based inspection was undertaken on 14 November

2016 to check the practice was meeting the regulations previously breached. For

this reason we have only rated the location for the key questions to which this

inspection related. This report should be read in conjunction with the full

inspection report of our inspection in February 2016. You can read the report

from our last comprehensive inspection by selecting the 'all reports' link for Mere

Surgery on our website at www.cqc.org.uk.

We found the practice had made improvements since our last

inspection. From the information we received, we found the practice was meeting

the regulations that it had previously breached.

We have changed the rating for this practice to reflect these changes.

The practice is now rated as good for the provision of safe, effective, caring,

responsive and well led services.

​

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice