This practice is rated as Good overall. (Previous inspection September 2017– Requires improvement)

The key questions 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 Mexborough Health Centre on 18 September 2017. The overall rating for the practice was requires improvement. The full comprehensive report from this inspection can be found by selecting the ‘all reports’ link for Mexborough Health Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 11 April 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 September 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The telephone and appointment system had recently been reviewed to make it easier for patients to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

• A member of the patient participation group (PPG) had completed the expert patient programme and facilitated a creative well being group for patients and their carers registered at the practice and from the local area supported by other members of the PPG and practice staff. The group met twice a month and provided those who attended with the opportunity to take part in various creative activities. People spoke very enthusiastically of the sessions and we were told how attendance had increased and how it benefited to address social isolation. 

The areas where the provider

should

make improvements are:

• Promote awareness of sepsis in the practice by providing notices and leaftets for patients and staff.

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 Mexborough Health Centre on 16 August 2016. The overall rating for the practice was good with requires improvement for being well-led. A further inspection took place on 16 March 2017 and the practice was good with requires improvement for being well-led. The full comprehensive report from the previous inspections can be found by selecting the ‘all reports’ link for Mexborough Health Centre on our website at www.cqc.org.uk.

This announced focused inspection was to review that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 March 2017. In addition, following feedback to the Care Quality Commission which raised specific concerns about care and treatment, this inspection reviewed the safe and effective domains.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. 
• Some risks to patients were assessed and managed others required review. For example, the provider did not have access to a defibrillator and we were told they shared the defibrillator with the dental service co-located in the same building. The dental service were unaware of this. We found a set of resuscitation guidelines dated 2008 in a treatment room. These have since been updated by the Resuscitation Council (UK) guidelines in 2015.
• Data showed patient outcomes were above the national average. Some audits had been carried out and we saw evidence procedures had changed, although this was not consistently cascaded to all staff.

• The practice had a number of policies and procedures to govern activity, but some were overdue a review. For example,the adult and child safeguarding policies were not practice specific, overdue a review from July 2016 and also contained out of date contact details.

The areas where the provider must make improvements are: 

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should: 

• Encourage staff to the record the details of incidents on the recording forms.

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 Mexborough Health Centre on 16 August 2016. The overall rating for the practice was good with requires improvement for being well-led. The full comprehensive report from August 2016 inspection can be found by selecting the ‘all reports’ link for Mexborough Health Centre on our website at www.cqc.org.uk. 

This inspection was an announced focused inspection carried out on 16 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 August 2016. This report covers our findings in relation to those requirements since our last inspection. 

Overall the practice is rated as good and remains requires improvement for being well-led. 

Our key findings were as follows:

• ​

  We reviewed the process for storing of blank prescription forms and pads and found they were securely stored and there were systems to monitor their use.

• We saw chaperone notices were available in the reception area and in treatment rooms.

• ​The providers' governance and risk management procedures required further review as some of the actions reported as being compliant by 31 January 2017 were still incomplete during this inspection. For example, actions identified as part of the fire risk assessment and legionella risk assessment had not been addressed. The practice responded to the issues pointed out during this inspection and submitted updated evidence to us after this inspection. However these issues should have been dealt with more proactively and been kept under regular review as part of the practice's previous action report submitted to us.

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 Mexborough Health Centre on 16 August 2016. Overall the practice is rated as good.

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.

• Although some risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, an 

  infection prevention and control audit had not been completed. The practice did not have a copy of the legionella risk assessment and were unaware of the actions they should be taking to reduce the risk of legionella. The practice did not have a fire risk assessment for the areas of the building they occupied.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had reviewed its appointment system following feedback from patients with urgent appointments available the same day.
• 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. 

• There had been some recent changes to the practice leadership and managerial structure. A salaried GP had become a partner and the practice manager was new in post. Staff were clear about the leadership structure and felt supported by management.The practice proactively sought feedback from staff and patients, which it acted on.

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

We saw one area of outstanding practice:

• A member of the patient participation group (PPG) had completed the expert patient programme and facilitated a creative well being group for patients and their carers registered at the practice and the from the local area supported by other members of the PPG and practice staff. The group met weekly and provided those who attended with the opportunity to take part in various creative activities. People spoke very enthusiastically of the sessions and we were told how attendance had increased and how it benefited those attending and helped to address social isolation.

The areas where the provider must make improvement are: 

• Ensure an infection prevention and control audit and fire risk assessment is completed and actions implemented in accord with the findings.
• Ensure environmental risk assessments are completed, particularly for areas highlighted on the risk log.
• Obtain copies of the legionella risk assessment and ensure actions identified are completed.

The areas where the provider should make improvement are:

• Review processes to ensure patients are informed of availability and the role of chaperones.

• Review the processes for staff appraisals to guarantee they are undertaken regularly.
• Monitor patient satisfaction with GPs and take action where appropriate to address feedback.
• Keep records of all staff indemnity arrangements.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice