Letter from the Chief Inspector of General Practice

We carried out a desktop review of St Mary’s Surgery on 21 September 2016. This review was performed to check on the progress of actions taken following an inspection we made in April 2015. Following that inspection the provider sent us an action plan which detailed the steps they would take to meet their breach of regulation. During our latest desktop review on 21 September 2016 we found the provider had made the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published in August 2016. This can be done by selecting the 'all reports' link for the St Mary’s Surgery on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

The practice had improved the systems ensuring that risk assessments and mandatory training was managed effectively so that patient safety is promoted and any risks that could affect the quality of care are reduced. This included:

• Fire safety had been strengthened so that patients had safe exits in the event of a fire.

• The chaperone policy and associated procedures had been reviewed to ensure that appropriate vetting and training took place of any staff undertaking these duties, promoting patient safety.

• Implementation of a system of risk assessment for any new staff to determine whether a Disclosure and Barring Service check was required according to their role and responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a desktop review of St Mary’s Surgery on 21 September 2016. This review was performed to check on the progress of actions taken following an inspection we made in April 2015. Following that inspection the provider sent us an action plan which detailed the steps they would take to meet their breach of regulation. During our latest desktop review on 21 September 2016 we found the provider had made the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published in August 2016. This can be done by selecting the 'all reports' link for the St Mary’s Surgery on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

The practice had improved the systems ensuring that risk assessments and mandatory training was managed effectively so that patient safety is promoted and any risks that could affect the quality of care are reduced. This included:

• Fire safety had been strengthened so that patients had safe exits in the event of a fire.

• The chaperone policy and associated procedures had been reviewed to ensure that appropriate vetting and training took place of any staff undertaking these duties, promoting patient safety.

• Implementation of a system of risk assessment for any new staff to determine whether a Disclosure and Barring Service check was required according to their role and responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

In December 2013, we found the practice wasn't meeting the regulation in relation to the management of medicines. We received an action plan from the provider on the 21 January 2014, telling us what action they would take to meet this essential standard.

We were told that the practice would be meeting the requirements of the regulation by 31 January 2014. During our follow up inspections on the 8 May 2014, we found the provider was meeting the requirements of the regulation. On this occasion we did not speak with people who used the practice.

St Mary’s Surgery also provided services from a branch surgery in central Southampton at Telephone House. Patients were seen at either surgery with staff working between the two sites. We were told all minor surgical procedures were completed at Telephone House as a clinical room suited for this purpose was located there. We did not visit Telephone House during this inspection.

We spoke with 18 patients who were attending the main surgery during our inspection. We also spoke with two of the five GP partners, the practice manager, four practice nurses, and five administrative staff. Most patients were happy with the service they received from the surgery and the staff. They told us they could always get a same day emergency appointment when they needed one. Patients said there was adequate time at each consultation with diagnosis and treatment options fully discussed and explained to them. One said “I am always able to ask questions, the doctors are good at explaining things”. Some patients felt they had to wait a long time after their appointment time, however, for other patients this was not a concern.

All patients said they were treated appropriately, with dignity and respect. All necessary recruitment and pre employment checks were in place and staff had completed induction and ongoing training. Staff were supported and received an appraisal each year. Arrangements were in place for staff to be able to recognise and report safeguarding children and vulnerable adults concerns. Infection control procedures were followed however, medicines storage was not secure.

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of patients using the service and others. Patient’s views were sought as part of the process to monitor the quality of the service provided.