This practice is rated as Good overall. (Previous rating August 2015 – Good)

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 Mount Pleasant Health Centre as part of our inspection programme.

At this inspection we found:

• 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 routinely reviewed the effectiveness and appropriateness of the care they provided. They ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• Improvements since our previous inspection included a patient’s garden allotment, physiotherapy, an emergency care practitioner, health navigation, E-Consult and a swifter triage system.
• The practice offered extended hours which included opening on a Sunday from 9am until 4pm.
• The practice had been successful with a bid to be part of a pilot for a first contact practitioner and now had a physiotherapist based at the practice. Healthcare Navigators (receptionists) booked patients directly to this service, which reduced the workload for GPs and increased their time with other patients.
• We saw examples of how the practice used technology and equipment to improve treatment and to support patients’ independence. For example, the introduction of E-Consult allowed patients to communicate with the practice online.
• The practice had been shortlisted by the General Practice Awards for the Patient Choice Surgery of the Year 2018 as a result of patient feedback about the care provided by the practice. The practice was in the top three practices nationally and staff from the practice were due to attend the awards ceremony at the end of November 2018.

The areas where the provider should make improvements are:

• The practice should continue to review its childhood immunisation programme in order to bring its achievement into line with World Health Organisation (WHO) targets

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

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

Letter from the Chief Inspector of General Practice

We inspected Mount Pleasant Surgery on 5th August 2015 as part of our comprehensive inspection programme.

We have rated the practice overall as providing a good service. Specifically we found the practice to be good for providing responsive, safe, effective, caring and well led services. It was also found to be good in providing services for all the patient population groups, older people, people with long-term conditions, working age people, people experiencing poor mental health (including people living with dementia), and families, children and young people.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

• There were arrangements in place to respond to the protection of children and vulnerable adults and to respond to any significant events affecting patients’ well-being.

• The practice worked well with other health care services to enable a multi-disciplinary approach in meeting the health care needs of patients receiving a service from the practice.

• The practice managed complaints well and took them seriously. Information about how to complain was available and easy to understand.

• There was a clear management structure with approachable leadership. Staff were supported and had opportunities for developing their skills, were well supported and had good training opportunities.

• The practice had good facilities and was well equipped to treat patients and meet their needs. Patients commented how helpful the staff were in trying really hard to get them a convenient appointment. This was reflected in the data from the national GP survey, 99% of 125 patients who responded reported a good overall experience of getting an appointment at a convenient time (the national average was 94%).

• The practice had a vision and informal set of values which were understood by staff. There were clear clinical governance systems and a clear leadership structure in place.

We saw one area of outstanding practice:

• The practice helped to set up a charity called ‘Friends of Mount Pleasant’ which was based at the practice and was run by a member of practice staff. The ‘Friends’ helped by fundraising to provide additional equipment for the Health Centre. They also provided a group of volunteer drivers to help patients with transport difficulties, arranged regular meetings for carers and liaised with the medical teams to discuss future improvement to the Health Centre’s facilities. They also offered other services, for example a befriending service and currently fund a toenail cutting service.

The provider should:

• Ensure all risk assessments are well documented including the legionella risk assessment. Actions required within the fire risk assessment should be recorded as completed.

• Recruitment records should be robust with copies of required documentation retained on file.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with nine patients and heard from three of the patient reference group from the practice who informed us they thought the practice was “very good” “absolutely fine” and “brilliant with children”.

Patients were pleased with the service they received from the practice. Patients told us they had been involved in the decisions made about their care. We were told that staff treated people with respect and dignity. One patient said “On every occasion I have been involved in the decision made. I have been very happy with the GPs, nurses and healthcare assistants with whom I have dealt.” Patients said it was easy to get an appointment when they wanted.

Patients felt confident and safe in the care of the doctor and nurse. Staff were clear about what action they would take if they saw or suspected any bad practice or abuse. Staff had been given information of safeguarding adults but had not yet received formal training in this subject.

There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date. Staff spoke about the supportive environment and confirmed that they had access to adequate training.

The practice was organised and well led. There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.