This practice is rated as good overall. (Previous rating February 2018 – 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 St Clements Surgery over two days in February 2018 and March 2018 as part of our inspection programme where the surgery was rated as requires improvement overall. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements. The full comprehensive report of all previous inspections can be found by selecting the ‘all reports’ link for St Clements Surgery on our website at

This inspection was an announced comprehensive inspection carried out on 26 November 2018 to check whether the providers had taken action to meet the legal requirement’s’ as set out in the requirement notices. The report covers our findings in relation to all five key questions and six population groups.

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.
• A sample of care records showed that patients prescribed high-risk medicines as well as other medicines which required closer monitoring were being managed in line with the practice protocol, which reflected national guidance for safer prescribing.
• 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.
• The practice had a comprehensive programme of quality improvement activity which demonstrated quality improvements. Clinical leads routinely reviewed the effectiveness and appropriateness of the care provided and implemented action plans to improve any identified areas.
• The practice was aware of their 2017/18 Quality Outcome Framework (QOF) performance and taking action to improve clinical areas where performance was below local and national averages. Discussions with staff and examples provided during as well as following our inspection, confirmed this.
• Results from the 2018 annual national GP patient survey showed patients felt staff involved and treated them with compassion, kindness, dignity and respect. Completed Care Quality Commission (CQC) comment cards were in line with these views.
• The 2018 national GP patient survey showed patients did not always find the appointment system easy to use and were not always able to access care when they needed it. Completed CQC comment cards were in line with these views. The practice was aware of patients views and taking a number of actions to improve access as well as reducing waiting times. Unverified data provided by the practice following our inspection, showed improvements in patient satisfaction.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. For example, the practice demonstrated shared learning and actions taken as a result of complaints and incidents.
• At this inspection, we found that the practice had reviewed and implemented systems which demonstrated a more effective systematic approach to maintaining and improving the quality of service delivery. For example, the governance framework had been strengthened which in turn supported the delivery of the strategy and oversight of processes.

The areas where the provider should make improvements are:

• Continue taking action to improve the uptake of national screening programmes and childhood immunisations.
• Establish a process to increase the number of medicine reviews carried out for patients with a learning disability and patients receiving support for substance misuse.
• Continue following actions to reduce the practice exception reporting rates.
• Continue taking action in response to patient satisfaction survey results.

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 Clements Surgery on 16 October 2015. Overall the practice is rated as good.

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

• The practice was located in one of the most deprived and multicultural areas in the country. Within the challenges this presented we found the practice proactive, flexible and responsive to its population needs to ensure patients were not disadvantaged and achieved positive health outcomes.
• The practice had robust processes to ensure the most vulnerable patients were protected from the risk of harm.
• Staff understood and fulfilled their responsibilities to raise concerns. There was an open culture for reporting incidents and near misses. Incidents were thoroughly investigated and used to support learning and service improvements.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice worked well with other health professionals to ensure patients’ needs were met.
• Staff had received training appropriate to their roles.
• 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 a flexible system to support the needs of different patients in accessing care. Open appointments for walk in patients meant less bookable appointments were available which resulted in lower satisfaction scores than other practices for access to appointments.
• 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. There was a culture of learning and improvement within the practice.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw an area of outstanding practice:

• Staff understanding and vigilance in safeguarding had led to the successful protection of several vulnerable patients. The practice reflected on such events to identify whether there was anything they could have done differently or better. A safeguarding audit was undertaken to ensure staff knowledge in order to protect patients resulting in increased staff confidence in raising concerns. Key staff had received training in female genital mutilation (FGM) so that they were aware and vigilant of the risks and was relevant to the population served.

• The practice was very proactive and flexible in the way in which services were delivered which helped ensure all patients could access care and support and were encouraged to do so. There were numerous examples including: the translation of information on childhood immunisations to encourage uptake from the Somalian population; the identification of women who would benefit from more frequent cervical screening, home visits for carers who could not leave the person they were caring for and open appointments for walk in patients.

The areas where the provider should make improvement are:

• Maintain records to demonstrate and provide assurance that emergency equipment such as oxygen and defibrillator have been checked and are in good working order.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Requires improvement overall. (Previous inspection October 2015 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

At this inspection we found:

• The practice had systems in place to manage risk so that safety incidents were less likely to happen. Records viewed during our inspection, showed that when incidents did happen, the practice learned from most of them and were able to demonstrate improvements made to reduce recurrence.

• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. However, monitoring of actions aimed at improving quality and effectiveness in some areas of medicines management was not effective.

• Results from the July 2017 annual national GP patient survey showed patients felt they were treated with compassion, dignity and respect. Completed Care Quality Commission comment cards were mainly in line with the results.

• Patients did not always find the appointment system easy to use and found they were not always able to access care when they needed it. The practice was aware of the issues and taking action to improve access.

• The leadership, governance and culture were used to drive and improve the delivery of its service. All staff were involved in the development of the practice. However, we found some systems and processes were not embedded to ensure compliance with practice policies and procedures. For example, oversight of recruitment checks, training, significant events and complaints was not effectively managed.

The areas where the provider must make improvements are

• Ensure care and treatment is provided in a safe way to patients

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

The areas where the provider should make improvements are:

• Ensure effective monitoring of training needs so that persons employed in the provision of the regulated activity receive appropriate training necessary to enable them to carry out the duties.

• Ensure incident reports and complaints clearly demonstrate details of investigations and actions taken to remedy the situation and prevent further occurrences.

• Ensure medication reviews are carried out with patients in receipt of interventions for substance and alcohol dependency and continue to improve communication with community teams to ensure safer monitoring of patients treated in the community.

• Continue exploring measures to improve the uptake of cervical, breast and bowel screening as well as childhood immunisations.

• Continue establishing methods to improve patient satisfaction in areas identified from survey results and patient feedback.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice