We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at College Street Medical Practice on 15 November 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection was good. However the practice was rated requires improvement for providing caring services.

As a result of this rating an announced focused inspection took place on 9 August 2017 to assess the improvements made to the caring key question. The practice is rated as requires improvement for providing caring services.

Our key findings were as follows:

• There had been some improvement in the latest results published from the GP patient survey conducted in January 2017. However this was only two months following our inspection on 15 November 2016.
• We received positive comment cards from patients who had attended the practice in the week prior to this inspection.
• We witnessed staff being friendly and approachable to patients during the inspection, often knowing the patients by name.
• Patients told us the staff were caring and treated them with kindness, and never felt rushed.
• The practice had a log of medicine alerts and retained information on how they were acted upon and actions taken.
• A new care coordinator was proactively reviewing patients registered as carers to ensure they had the support and care they required.
• However, the practice had not developed an action plan to address areas of the national GP patient survey which showed results which were lower than the national average.

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 College Street Medical Practice on 13 August 2015. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise significant events and safeguard patients from abuse. All opportunities for learning from internal and external incidents were maximised.

• Some risks to patients were assessed and well managed, with the exception of those relating to the environment, infection control and management of the service.

• Most patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Data reviewed showed the majority of patient outcomes were comparable to the local and national averages.

• Staff worked closely with other services to ensure that patients’ needs were met.

• The majority of patients said they were treated with compassion, dignity and respect and felt they were involved in their care and decisions about their treatment.

• Most patients were able to access care and treatment when they needed it, with urgent appointments available the same day. However, nationally reported data showed some patients did not always find it easy to make an appointment with a named GP and continuity of care was not always maintained.
• The practice implemented suggestions for improvements as a result of feedback from patients and the patient participation group (PPG).

• Information about how to complain was available and easy to understand.

• There was a clear leadership structure and most staff felt supported by management.

• The clinical leadership and governance arrangements required strengthening to ensure: robust systems were in place to assess and monitor the service provision; and a practice wide approach to ensuring safe care and treatment. We also noted that the practice was undergoing various changes to drive improvements, following the appointment of additional nursing staff.

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

The areas where the provider must make improvements are:

• Ensure the implementation and regular review of formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Ensure records relating to staff employed and the management of the regulated activities are sufficiently detailed and up to date. This includes information related to staff training and personal records, policies and procedures and investigations related to significant events and complaints.

• Ensure identified areas of improvement in relation to infection prevention and control are addressed.

• Ensure notifiable incidents are reported to the Care Quality Commission.

The provider should also:

• Improve the availability of non-urgent appointments and continuity of care for patients.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Carry out re-audits to improve patient outcomes and clinical audits related to minor surgery.

• Ensure all staff are fully supported with formal induction and training relevant to their role.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at College Street Medical Practice on 15 November 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection was good.

However the practice was rated requires improvement for providing caring services.

The full comprehensive reports can be found by selecting the ‘all reports’ link for College Street Medical Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection on 9 August 2017 to assess improvements made in the area of ‘Caring’. The practice remained rated as requires improvement for providing caring services.

This inspection was an announced focused inspection carried out on 17 September 2018 to review actions taken by the practice since our previous inspection in August 2017. This report covers our findings in relation to actions taken by the practice since our last inspection in the area of ‘Caring’.

Overall the practice remains rated as ‘Good’. The practice is now also rated ‘Good’ for providing caring services.

Our key findings were as follows:

• The latest results published from the GP patient survey conducted in 2018 showed the results in the indicators related to caring were in line with local and national averages.
• We received positive comment cards from patients who had attended the practice in the two weeks prior to this inspection.
• We witnessed staff being friendly and approachable to patients during the inspection.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice