Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit at St. Margarets Medical Practice on 14 June 2016. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe and well led services.You can read the report from the comprehensive inspection on 14 June 2016, by selecting the 'all reports' link for St Margarets Medical Practice on our website at www.cqc.org.uk.

This was a focused desk based review of St Margarets Medical practice carried out on 20 December 2016 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. Overall the practice is now rated as Good.

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

• Since our comprehensive inspection in June 2016, the practice had applied for disclosure and barring (DBS) checks for non-clinical staff members who chaperoned (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). The practice policy on chaperoning had been updated with the recognised national guidelines and staff had completed the relevant training for this role in August 2016.
• We received confirmation that Disclosure and Barring (DBS) checks had been completed for all the nursing staff and the practice had updated the recruitment procedures to ensure all staff due to commence at the practice had the relevant checks in place.

• All staff had completed an occupational health vaccination and immunisation risk assessment form. Staff had been assessed by the occupational health department and had been offered vaccinations based on guidelines for staff working in general practice. An up to date list of staff and their immunisation status was now in place and copies of vaccination certificates were stored on the employment record for each member of staff

• We saw that an electrical wiring system check that had been identified as a risk during the fire risk assessment completed in July 2015 had been actioned.

• The practice had introduced a formal meeting schedule to ensure all staff received effective communication.

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 Margarets Medical Practice on 14 June 2016. Overall the practice is rated as requires improvement.

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

• There was an effective system in place for reporting and recording significant events.
• The practice had strong, visible clinical and managerial leadership and staff felt supported by management.
• 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.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice was proactive in promoting patient awareness through a monthly newsletter and using social media.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that monthly multidisciplinary team meetings took place.
• Governance and risk management arrangements were in place, but no risk assessments had been completed in the absence of disclosure and barring checks (DBS) for members of the reception team who occasionally chaperoned.
• Some staff who acted as chaperones were unaware of the recommended chaperoning guidelines when observing treatments and examinations.
• The last health and safety risk assessment had identified an electrical system check was required; however this had not been completed.

The areas where the provider must make improvement are:

• Ensure all staff are risk assessed in the absence of a Disclosure and Barring Service (DBS) check when carrying out chaperoning duties, including assessing risk in relation to staff to ensure understanding and competency when undertaking chaperone duties.
• Take action to address identified risks following health and safety risk assessments undertaken.
• Ensure records are kept to evidence staff are up to date with the immunisations recommended for staff who work in general practice

The areas where the provider should make improvement are:

• Review systems for ensuring effective communication is in place for all staff; including non clinical staff.
• We reviewed five personnel files and found Disclosure and Barring Service (DBS) checks from previous employers for some of the nursing team. Complete risk assessments for all employees who had not had DBS checks completed at time of recruitment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice