This practice is rated as Good overall.

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 Sancta Maria Medical Centre on 10 July 2018 as part of our inspection programme. We carried out a comprehensive inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

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 it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had clear governance arrangements and staff understood their roles and responsibilities. We found some areas of governance were ineffective. For example, reviewing and updating practice policies.
• National data showed that the practice was performing in line with national averages for most indicators. Where the practice had performed below national average they had acknowledged it and worked on improving the outcomes.
• The practice involved patients in regular reviews of their medicines.
• There was a system for receiving and actioning safety alerts.
• Environmental risk assessments had been completed and were effective at monitoring risk.
• The practice had identified 1.4% of its practice list as carers by highlighting them during registration and clinical consultations.
• The practice was clean and tidy and staff had reviewed aspects of their infection prevention control however had not carried out an annual infection control audit.
• The practice had considered equipment for use in the treatment of patients, including in the event of a medical emergency.
• Staff had received some training applicable to their role however we found there was training that had not been completed such as fire safety training. Staff we spoke with felt that additional time was required to carry out their duties and training.
• Staff we spoke with on the day said they had not received information regarding sepsis and would benefit from further training.
• Data from the national GP patient survey published in July 2017 showed patients rated the practice in line with national averages for all aspects of care.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had found it difficult to form a patient participation group. However, they had monitored the views of their patients through internal survey and online reviews and communicated with them through their practice website and the information board in the waiting area. We received 23 positive comment cards regarding the care and service at the practice.

The areas where the provider should make improvements are:

• Strengthen the system for infection control by carrying out an annual infection control audit.
• Improve the system for updating policies so they contain the most current information.
• Improve staff training in relation to the signs and symptoms of sepsis and fire safety procedures.

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.