Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of St Mary Street Surgery on 24 May 2016. The overall rating for the practice was requires improvement, with the safe and well-led domains rated as requiring improvement. The provider had resolved some of the concerns for the safe and well-led domains at our focused follow-up inspection on 28 February 2017. However, the provider had not rectified all the issues found previously in our comprehensive inspection and the practice remained as requiring improvement for providing safe and well-led services. Following the focused follow-up inspection we again issued two requirement notices. A notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment; and a notice was issued due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to good governance.

Within our last inspection report we reported that the provider must:

• Ensure that confidential records, including patient medical records, were held securely at all times and within appropriate containers to remove the risk of damage and destruction.
• Ensure that all actions from the fire risk assessment had been completed including the electrical installation safety check, to ensure staff were appropriately trained in fire safety including key members of staff who led the team and patients to safety.

In addition, the provider should:

• Ensure blank prescription paper and pads were kept secure at all times.
• Ensure formal risk assessments took place when staff were employed before all appropriate checks had been received.
• Ensure actions, as identified from the practice legionella risk assessment were carried out.
• Improve its systems on how it monitored the quality of care and treatment provided to its patients, and ensure that when auditing took place this was discussed with all of the clinical team to share learning.

We found the practice needed to improve its systems on how it monitored the quality of the care and treatment provided to its patients. For example, minor surgery results were not monitored for complications or for diagnostic accuracy.

The comprehensive and focused follow-up inspection reports can be found by selecting the ‘all reports’ link for St Mary Street Surgery on our website at www.cqc.org.uk.

We undertook a subsequent focused follow-up inspection of the practice on 3 July 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

There were key findings across all the areas we inspected during this follow-up inspection. We saw documentary and other evidence that:

• The practice had assigned a dedicated room for medical records storage. The records were held in appropriate containers and the room had a lockable door that could only be accessed with a key, which was accessible by certain staff. In addition, we saw that blank prescription paper and pads were kept secure at all times behind locked doors that were only accessible to authorised staff.

• All actions from the fire risk assessment had been completed, including an electrical installation safety check. Fire warden training had been completed by key members of staff responsible for team and patient safety.

In addition, we saw documentary and other evidence that:

• The practice had a formal risk assessment in place if non-clinical staff were employed before all appropriate checks had been received.
• Actions identified from the practice legionella risk assessment had been carried out. These included a record of weekly water system flushing.
• Clinical audits had been completed and findings discussed with all the clinical team to share learning.

Following this inspection the practice was rated as good across all domains.

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 Mary Street Surgery on the 24 May 2016. The overall rating for the practice was requires improvement with the safe and well-led domains rated as requiring improvement.

The main areas where the practice must improve were;

• Ensuring consulting room access was restricted to ensure patient privacy.

• Ensuring blank prescriptions were kept secure and managed effectively.
• Ensuring patient medical records were kept secure and protected against damage and destruction.
• Ensuring the building was fit for purpose.
• Ensuring patients were monitored regularly to demonstrate quality and improvement including regular audits of minor surgery.
• Ensuring policies and procedures were standardised and kept up to date with current guidance and legislation.
• Ensuring there was a risk assessment for the treatment room with a damaged ceiling and actions were taken to ensure it was fit for purpose.

Following the last inspection we said that the practice should also improve by;

• Ensuring the electrical wiring at the practice had been appropriately maintained and that the practice had received a safety installation check, which should occur every five years.
• Ensuring there were regular fire safety drills undertaken
• Ensuring there was a risk assessment for legionella and any actions from it were addressed.
• Ensuring the recruitment process included retaining a proof of identity when new staff were recruited.

The full comprehensive report on the 24 May 2016 inspection can be found by selecting the ‘all reports’ link for St Mary Street Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 28 February 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 24 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice will remain rated as requires improvement.

Our key findings were as follows:

• Consulting rooms now had door locks and these were routinely locked when not in use or for patient privacy.
• Allocated blank prescriptions were now monitored and kept securely when allocated to individuals. However, prescription stock could be further secured.
• The practice had a plan in place to ensure all patient medical records were kept secure and within suitable containers. This would be completed by 31 March 2017. The practice had medical records kept securely within the practice. Although this could be further improved by ensuring cabinets were locked when not in use. Archived records were still kept within cardboard containers and not protected against damage and destruction.
• A number of improvements had been made to building including a new treatment/consulting room, an additional office, baby changing facilities in the downstairs toilet and a new storage cupboard for nursing supplies. Further works within the reception area were to be completed by 31 March 2017 which will improve patient accessibility and experience.
• Remedial repair work had been completed on the roof of the building to reduce the risk of water leakage into the treatment room. More investigation was required to find the root cause but a temporary fix had been completed. The practice had completed cosmetic work to upgrade the room including plastering walls, installing washable flooring; the window had been moved to improve patient privacy and natural light into the room.
• Three clinical audits had been completed in the last two years and discussions of the results from these audits will now be recorded in future clinical team meetings to ensure all clinical staff shared learning.
• Policies and procedures had been updated to reflect current guidance and legislation.
• Fire safety had improved, although further improvement was still required. The fire risk assessment had not been reviewed since July 2015. The practice provided us with evidence it had been reviewed following this inspection. Mandatory fire safety training had not been completed by three members of staff (one had recently started). Fire marshal training was due to be completed in March 2017 for two members of staff. A fire drill had been completed in October 2016 and we were informed that this will be undertaken on a six monthly basis.
• Part of the fire risk assessment was to complete an electrical installation safety check which had not been completed; the practice confirmed that this had now been arranged to be completed on 11 March 2017.
• A risk assessment for reducing the risk of legionella had been completed. Actions from this had not been addressed. The practice confirmed they had started to implement the control measures following this inspection.
• When new staff were recruited proof of identity was now retained and kept in their recruitment file. The practice needed to ensure where references and disclosure and barring service checks had not been received prior to employment that a risk assessment was carried out to ensure any risks had been mitigated.

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

Importantly, the provider must:

• Ensure patient medical records/confidential records were held securely at all times and within appropriate containers to remove the risk of damage and destruction.
• Ensure all actions from the fire risk assessment had been completed including the electrical installation safety check, to ensure staff were appropriately trained in fire safety including key members of staff who led the team and patients to safety.

In addition the provider should:

• Ensure blank prescription stock were kept secure at all times.
• Ensure formal risk assessments took place when staff were employed without all appropriate checks being in place.
• Ensure actions, as identified from the practice legionella risk assessment were carried out.
• Ensure patients were monitored to improve their outcomes and that when auditing took place this was discussed and recorded so all of the clinical team could share learning.

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 Mary Street Surgery on 24 May 2016. We had inspected this GP practice in August 2014 as part of our inspection programme pilot to test our approach going forward. We found there had been a recent change in the overall management of the practice with the employment of a strategic manager (January 2016) and operational manager (April 2016), and a change in the partnership with two new partners joining in 2015. The areas identified for improvement at our last inspection had not all been actioned however the new management team provided us with an action plan on how these issues would be addressed.

Areas identified for improvement in August 2014 were:

• The practice should improve access to the building and décor for the overall patient experience.

• The practice should provide alternative forms of information for patients such as easy read formats, pictures and models.

• The practice should implement a formal appraisal for staff.

• The plans to protect patient privacy and confidentiality in the reception area should be implemented in line with the practice action plan.

• The practice should consult with the appropriate agencies to ensure the appropriate arrangements were implemented with regards to fire safety.

• Staff should be up to date with safeguarding training, which should be at the appropriate level in line with the individual’s roles and responsibilities.

From this inspection 24 May 2016 our findings were:

Overall the practice is rated as requires improvement specifically in the domains of safe and well led, and good for the effective, responsive and caring domains.

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.
• Risks to patients were assessed and well managed, however, some environmental risks were not properly assessed or managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained in order to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients told us 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.
• Patients told us they found it easy to make an appointment; there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by management.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• The provider must review security arrangements in order that access to consulting rooms is restricted to protect patient privacy and so that prescription paper left in printers in consulting rooms is secured.

• The provider must do all that is reasonably practicable to ensure the building is fit for purpose including having sufficient resources for the purchase, service, maintenance, renewal and replacement of premises (including grounds) and equipment to ensure it is safe.

• The provider must undertake risk assessment of the damaged ceiling in the first floor treatment room and demonstrate what mitigating actions are to be taken to ensure it is fit for purpose.

• The provider must do all that is reasonably practicable to ensure paper medical records were stored in accordance with Records Management: NHS Code of Practice Part 1 so that records were stored securely and protected against accidental loss, including corruption, damage or destruction and kept secure and confidential at all times.

• The provider must ensure that policies and procedures are standardised and the team operate within best practice guidance so that operations such as signing prescriptions for medicines which requiring additional monitoring for safety reasons is consistent.

• The provider must ensure the practice undertakes regular audits such as that for minor surgery to demonstrate quality and improvement.

The areas where the provider should make improvement are:

• The practice should obtain evidence of that an electrical installation safety check has been carried out.

• The practice should undertake regular fire safety drills.

• The practice should obtain a copy of the Legionella assessment for the premises.

• The practice should hold photographic evidence of identity for staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

St. Mary Street Surgery is a semi-rural practice which provides primary care services to patients living in Thornbury, South Gloucestershire, Monday to Friday during working hours. In addition, there are a range of clinics for all age groups, specialist nursing treatment and support.

As part of our inspection we spoke with other organisations, such as: the South Gloucestershire Clinical Commissioning group; the local Healthwatch; and other healthcare providers, to share what they knew. We also talked with patients and staff. We looked at the practice facilities which with the exception of the treatment room had not had the decoration updated.

The practice used a range of information to identify risks and improve quality regarding patient safety. They had a system for reporting, recording and monitoring significant events. The practice had systems which recognised and supported patients who were at risk of abuse. The practice had written guidance to support staff with the recruitment and selection process of new staff. Patients were treated by sufficient, suitably qualified staff. Patients were cared for in a safe environment. The practice had the equipment, medicines and procedures to manage foreseeable patient emergencies. Patients were protected from the risks of unsafe medicine management procedures. Patients were cared for in an environment which was clean and reflected good infection control practices.

Patients’ care and treatment was delivered in line with recognised best practice standards and guidelines. The practice met nationally recognised quality standards (the Quality and Outcomes Framework - QOF) for improving patient care and maintaining quality. For example, the management of patients with long term conditions and compared favourably with other practices in the area. Patient care was improved by the effective monitoring of treatment. Patients’ rights were protected with regards to the consent process. Patients' care was co-ordinated and managed by the practice to enable appropriate referrals to other healthcare providers. Patients had access to a range of health promotion information. 

Patients were generally positive about their care and treatment. This was supported by results from the 2014 GP National Patient Survey, which demonstrated 95% of respondents from the practice had confidence and trust in their GP. Patient privacy and confidentiality was not easily maintained in the practice waiting area. The practice was aware of the situation and had started to address the issue, for example: relocating a telephone and work station to a room away from patient areas. Patients were involved in treatment choices.

Patients were generally able to get an appointment when they needed it. Of the respondents who completed the 2014 GP National Patient Survey 98% said their last appointment was convenient for them. However, there were areas requiring change, for example: contacting the practice by telephone during peak periods involved long waiting times. Patients with mobility needs could not gain access to the practice without assistance. The main door was not automated and there was no doorbell to summon assistance. Patients with communication difficulties had access to help. Patients had access to the practice complaints procedure via the practice leaflet and in the practice waiting area.

Patients were cared for by staff who were aware of their roles and responsibilities for managing risk and improving quality. Patients’ views on the service were listened to. The practice demonstrated a focus on learning. GPs and nurses were encouraged to update and develop their clinical knowledge and skills. The practice monitored significant events and used the learning to improve practice.

The practice supported older patients and patients with long term conditions by offering advice and support through specialist clinics, screening and evidence based information. The practice supported mothers, children and young people by working with other healthcare providers. The practice supported the working age population and those recently retired by offering a flexible appointment system. The practice supported patients in vulnerable circumstances by the early identification and protection of patients at risk. The practice supported patients experiencing poor mental health by regular monitoring of their treatment and support needs.

Please note that when referring to information throughout this report, this relates to the most recent information available to the Care quality Commission (CQC) at that time