We carried out an announced comprehensive inspection at Queen Mary Practice on 16 May 2017. The overall rating for the practice was overall Good, with the exception of key question ‘safe’ which was rated as requires improvement. The full comprehensive report on the May 2017 inspection can be found by selecting the ‘all reports’ link for Queen Mary Practice on our website at www.cqc.org.uk.

This inspection was a focused inspection carried out on 27 July 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 16 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated as Good.

Our key findings were as follows:

• Systems and processes designed to minimise risks to patients were effective. The practice had streamlined safeguarding policies which contained information about who to escalate safeguarding concerns to internally and externally.
• There was a revised system for reviewing uncollected prescriptions held at the practice.
• The practice regularly reviewed their performance in terms of providing good clinical outcomes for patients.
• Complaints at the practice were handled in accordance to recognised guidance.
• The practice had identified 62 patients as carers, which is over 1% of the practice list size.
• The practice had reviewed its infection control policy and conducted a comprehensive internal infection control inspection. However, the last audit had taken place more than three months ago, which contradicts the practice infection control policy which states the inspections should be conducted quarterly.
• There was evidence that a recent Legionella risk assessment had been conducted.

There were also areas of practice where the provider should make improvements.

The provider should:

• Review the Infection Prevention and Control Policy in place at the practice to ensure that internal infection control inspections are conducted according to the schedule specified.

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 Queen Mary Practice on 16 May 2017. 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 a system in place for reporting and recording significant events.
• Some of the systems and processes designed to minimise risks to patients were not effective. The practice had more than one child safeguarding policy which contained different information about who to escalate safeguarding concerns too externally and, though the practice had identified patients who were vulnerable, there were no alerts placed on these patients’ records. The practice did not have an effective system in place for reviewing uncollected prescriptions. We identified a number of infection control issues on the day of the inspection; the practice provided evidence that they had previously attempted to rectify these issues by raising them with the management company who were responsible for the building.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• 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.
• Patient feedback indicated that it was easy to make an appointment with a named GP and there was continuity of care, 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. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must improve

• Ensure that risks to the health and safety of service users are assessed and mitigated; specifically those associated with safeguarding and the management of medicines.

The areas where the provider should improve

• Provide apologies in complaint response where appropriate and information on how to escalate the complaint.

• Regularly review the recording of practice performance in respect of clinical outcomes for patients.

• Review the practice’s policy framework to ensure that policies are regularly updated, contain the relevant information and that the most up to date versions are accessible to staff.

• Continue to liaise with the property management company to ensure that infection control risks including those with associated with Legionella are assessed and/or mitigated.

• Work to improve the identification of patients with caring responsibilities to be able to provide appropriate support and signposting.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice