This practice is rated as Good overall. (Previous rating May 2018 – Good)

The key questions at this inspection are rated as:

Are services well-led? - Good

We carried out an announced focused inspection at St Peters Hill Surgery on 2nd October 2018. The practice had previously been rated as good overall in May 2018. However were rated as requires improvement in delivering well-led services. This inspection was to investigate whether the governance systems had been implemented to improve systems for complaints, infection control, staff training and monitoring of refrigerator temperatures.

At this inspection we found:

• The practice had reviewed and taken action on the report published in May 2018 and implemented systems and processes to improve the practice performance.
• The system for complaints and significant events ensured that incidents were investigated and reported on in a timely matter. We saw that staff members were involved with the process and the practice understood the duty of candour where appropriate.
• The practice had a system to manage infection prevention and control and had implemented a new cleaning schedule for all areas of the practice.
• The management of staff records and training was well managed and alerted staff when training was due to be completed.
• Refrigerators temperatures were monitored twice daily and secondary thermometers were in use.

The areas where the provider should make improvements are:

• The provider should hold an immunisation record for staff.
• Ensure that back up thermometers provide accurate information.
• Continue developing the meeting schedule within the practice and providing accurate meeting minutes.

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 carried out an announced comprehensive inspection at St Peters Hill Surgery on 31 October 2017. Overall the practice is rated as good..

Our key findings were as follows:

• There was an effective system in place to deal with safeguarding and staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

• There were processes for handling repeat prescriptions which included the review of high risk medicines.

• The practice had some systems to minimise risks to patient safety. Evidence was not available on the day of our inspection either that all risks had been assessed or where those that had been assessed that mitigating actions identified had been implemented. However evidence was provided following our inspection.
• The systems in place for infection prevention and control needed strengthening.

• We found that refrigerators used to store vaccines did not have a secondary thermometer in place in order to cross-check the accuracy of the temperature. The practice took action on the day of inspection to rectify this. The refrigerators had not been serviced annually but this was carried out following our inspection.

• Staff were aware of current evidence based guidance however this was not discussed formally at clinical meetings.

• We were not able to access all recruitment information on the day of our inspection and therefore could not be assured that all necessary employment checks had taken place.

• Staff told us they had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, not all training records were available on the day of inspection. Not all staff had received an appraisal in the last 12 months but the practice told us these had been completed following the inspection..
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. However, some aspects of the complaints procedures needed development.
• Patients commented that they were pleased with the care they received and were able to get appointments when they needed them.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure whereby staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

• Not all systems and processes within the practice were operated effectively. Governance arrangements were in place but some areas identified during our inspection indicated a lack of oversight.

The areas where the provider must make improvement are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. More detail can be found in the requirement notice section at the end of this report.

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 Peter's Hill Surgery on 3 March 2015. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• 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 practice proactively sought feedback from staff and patients, which it acted on.

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

Importantly the provider should

• Improve patient ability to get through to the surgery by phone.
• Improve patients overall experience of making appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice