Letter from the Chief Inspector of General Practice

When we undertook a comprehensive inspection of St Melor House

Surgery on 29 November 2016 we found a number of regulatory breaches and the

practice was rated as requires improvement. We undertook a follow up desk-based

inspection of St Melor House Surgery on 19 June 2017 to review the actions

taken by the practice to improve the quality of care and to confirm that the

practice was meeting legal requirements. We found that the practice had made

significant improvements although they were still in breach of the regulations

relating to staffing. We amended our rating of the practice so it was rated

Good overall and for providing Safe, Caring, Responsive and Well-led services,

and rated as Requires Improvement for the provision of Effective services.

We said that they must:

• Ensure staff receive the essential training appropriate to their

  role.

We also said they should:

• Continue to work to encourage patients to join and participate

  in the patient participation group.

The reports of the full comprehensive inspection carried out on

29 November 2016 and follow up desk-based focused inspection carried out on 19

June 2017 can be found by selecting the ‘all reports’ link for St Melor House

Surgery on our website at

www.cqc.org.uk

.

This report covers the announced focused inspection visit we

carried out at St Melor House Surgery on 20 December 2017. This was to

confirm the practice

had carried out their plan to meet the legal requirements in relation to the

breaches in regulations we identified in our previous inspection on 19 June

2017.

Overall the practice continues

to be rated as Good and requires Improvement for providing effective services.

Our key findings were as follows:

• We saw evidence that most of the mandatory training we had

  identified as not being completed at our last inspection had now been

  completed. For example, all the GPs had been trained to level three in child

  safeguarding.

• We found that

  one clinician had not received Mental Capacity Act (MCA) training and another

  had not received fire awareness training.

• The practice

  had taken steps to encourage patients to join the patient participation group. A

  meeting date had been agreed and we saw evidence some patients had confirmed

  they wished to attend.

There were areas of practice where the provider needs to make

improvements. Importantly, the provider must:

• Ensure staff

  receive the essential training appropriate to their role.

   

In addition the provider should:

• Review their policies and procedures for identifying essential

  training appropriate to each staff member and communicating this requirement to

  staff.

• Continue to work to develop a mechanism for gathering feedback

  from 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 St Melor House Surgery on 29 November 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• The practice did not have written policies or procedures setting out how significant events or safeguarding concerns should be managed.

• Apart from one member of staff, the practice had no evidence that any other staff had received training in infection control, Mental Capacity Act 2005, health and safety or fire training. Not all staff had been trained to the recommended level in child safeguarding appropriate to their role.

• The practice did not always carry out all the appropriate recruitment checks prior to employing staff.

• Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and fire drills.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• The practice was above average for its satisfaction scores on consultations with GPs and nurses. For example, 96% of patients said the last GP they spoke with was good at treating them with care and concern compared to the clinical commissioning group average of 89% and national average of 85%.

• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• Information about services and how to complain was available and easy to understand. . However, the practice system for reviewing complaints was not always used consistently.

• 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure all staff receive essential training such as safeguarding training and infection control training to a level appropriate to their role.

• Ensure staff and patients are protected by conducting regular fire drills.

• Ensure the practice has a policy and procedure on safeguarding which includes details of the safeguarding lead.

• Ensure all appropriate recruitment checks are carried out and recorded prior to employing new staff.

The areas where the provider should make improvement are:

• Ensure all policies such as those relating to are kept up to date

• Ensure the practices policies on safeguarding and significant events are embedded in the practice routine operations.

• Ensure the practice process and procedure for managing complaints is used consistently.

• Ensure that the practice develops effective strategies for encouraging patient participation in their patient participation group, and listening and responding to patient feedback.

• Ensure all sharp bins are appropriately labelled when placed into service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We undertook an announced focused inspection of St Melor House Surgery on 20 December 2017. This was to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous (follow-up, desk based) inspection on 19 June 2017. At that inspection the practice continued to be rated as Good overall. The practice continued to be rated as Requires Improvement for providing effective services, because not all of the mandatory training we had identified as not being completed at our June 2017 inspection had been completed. The reports of the follow up inspections carried out on 19 June 2017 and 20 December 2017, can be found by selecting the ‘all reports’ link for St Melor House Surgery on our website at www.cqc.org.uk.

This report covers the announced focused follow-up inspection we undertook at St Melor House Surgery on 14 August 2018, to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection on 20 December 2017.

Our key findings were as follows:

• All clinical staff had received training relevant to their role.
• All staff had completed mandatory training.
• The practice had reviewed their policies and procedures for identifying essential training appropriate to each staff member and communicated this requirement to staff.
• The practice continued to work to develop a mechanism for gathering feedback from patients. Specifically:

  • The practice had taken steps to develop a patient participation group, by advertising for members on the practice website and also on a noticeboard in the practice reception area. A patient participation group was formed in December 2017 and we saw agendas and minutes of meetings held in January 2018 and June 2018. Going forwards, the group plans to meet twice-yearly.
  • We saw documentary evidence that the practice is collating and analysing the results of a recent patient survey. The practice told us the results will be published in the next few months.

Overall the practice continues to be rated as Good, and is now rated Good for providing effective services.