We carried out an announced comprehensive inspection at this practice on the 18th November 2014 and at this time the practice was rated as good.

However, breaches of a legal requirement were also found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On the 6 May 2016 we carried out a focused review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in November 2014.

This report covers our findings in relation to those requirements and areas considered for improvement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Park Street Surgery on our website at www.cqc.org.uk.

The findings of this review were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Appropriate recruitment checks had been carried out for staff. The practice had undertaken checks for all staff members.

• The practices complaints policy had been updated in line with recognised guidance and contractual obligations.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Park Street Surgery. The practice is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on 18 November 2014 at the practice location in Park Street, Bootle. We spoke with patients, relatives, staff and the practice manager.

The practice was rated as Good. They provided effective, responsive, caring and compassionate care that was well led and addressed the needs of the diverse population it served.

Our key findings were as follows:

• The practice had a good track record for maintaining patient safety. Effective systems were in place to ensure patients were safe from risks and harm. Incidents and significant events were identified, investigated and reported. Lessons learnt were disseminated to staff. However improvements were required to ensure staff were safely recruited and required information was held in relation to staff.

• Patients spoke highly of the practice. They were very pleased with the individualised care given by all staff and they told us staff were kind, compassionate and caring.

• The practice served a diverse population in a deprived area of Liverpool. The practice provided good care to its population taking into account their health and socio economic needs. Patients were listened to and feedback was acted upon. Complaints were managed appropriately.

• Patient’s needs were assessed and care was planned and delivered in line with current legislation and guidance.

• The practice continued to monitor, evaluate and improve services. They worked in collaboration with the CCG and NHS England. Staff enjoyed working for the practice and felt well supported and valued.

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

Importantly, the provider must:

• Ensure full and complete required information relating to workers is obtained and held when recruiting staff. The practice should ensure its recruitment arrangements are in line with Regulation 21 and Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. This must include a Disclosure and Barring Service (DBS) check for all staff with chaperoning responsibilities.

In addition the provider should:

• Ensure all audits follow a consistent format and are shared and disseminated across all staff. The audit cycle should be fully completed in order to demonstrate actions taken have enhanced care and improvements have been made.

• Ensure all staff who undertake chaperone duties are trained and competent to do so.

• Ensure the complaints policy was reviewed and in line with recognised guidance and contractual obligations for GPs in England. There should be an up to date information leaflet advising patients of how to complain and other bodies they can go to when their complaint is not resolved

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice