This practice is rated as good. (Previous inspection 15 May 2018 – rated good overall).

The practice was last inspected on 15 May 2018 and the key questions were rated as:

Are services safe? – good

Are services effective? – good

Are services caring? – good

Are services responsive? – good

Are services well-led? – requires improvement

We carried out an announced focused inspection at Minster Surgery on 6 November 2018. We followed up on previous areas identified for improvement during our inspection on 15 May 2018. The practice was required to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

At this inspection we found:

• The practice had systems in place to identify, manage and mitigate risks. They identified learning opportunities and shared this with their extended team to improve practice.
• The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
• The practice had established systems for following up on patients who failed to collect their medicines from the dispensary.
• The practice had conducted risk assessments and had followed up on actions to mitigate the risks to patients.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Minster Surgery on 29 January 2015. Breaches of the legal requirements were found. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook this focussed inspection on 5 July 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Minster Surgery on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Minster Surgery on 29 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing effective, caring, responsive and well-led services. It was also good for providing services to older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). It required improvement for providing safe services and the concerns which led to this rating applied to all population groups.

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. 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, with the exception of some areas of training that had not been undertaken, although 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 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 practice proactively sought feedback from staff and patients, which it acted on.

We saw an area of outstanding practice:

• GPs undertook routine ‘mood screening’ for all new mothers at post-natal checks and followed-up non-attendance to help ensure signs of depression in new mothers was identified quickly. Double appointments were routinely offered to those patients who had been newly diagnosed with mental health issues.

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

Importantly the provider MUST:

• Provide a safe and effective operating system in relation to preventing, detecting, and controlling the spread of infection, which includes having records and evidence of an audit programme, cleaning activity schedules and appropriate infection control training for staff.
• Provide a safe and effective operating system of recruitment, which includes obtaining DBS checks for administration staff who undertake chaperone duties.

Also, the provider SHOULD:

• review the policy arrangements for safeguarding vulnerable adults
• review the staff training requirements in relation to safeguarding vulnerable adults, chaperone duties, and the Mental Capacity Act 2005
• follow the practice recruitment policy to ensure all checks are in place when staff are employed
• review how risks are recorded, assessed and monitored within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice