We carried out an announced comprehensive inspection at St Mary’s Medical Centre on 17 October 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for St Mary’s Medical Centre on our website at .

After the inspection in October 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced comprehensive responsive follow up inspection carried out on 16 May 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 17 October 2017.

The inspection carried out on 16 May 2018 found that the practice had responded to the concerns raised at the October 2017 inspection. The overall rating for the practice is now good.

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

At this inspection we found:

• There was an effective system for reporting and recording significant events.
• Clinical equipment in GPs’ home visit bags was now up to date with calibration.
• The practice had made improvements to the arrangements for managing infection prevention and control.
• The practice had revised their system that managed notifiable safety incidents.
• Risks to patients, staff and visitors were now being assessed and managed in an effective and timely manner.
• The practice had made improvements in the timely processing of incoming records that required the attention of clinical staff.
• Improvements to the management of medicines helped keep patients safe.
• The practice routinely reviewed the effectiveness and appropriateness of the care they provided. They ensured that care and treatment was delivered according to evidence- based guidelines.
• Data from the Quality and Outcomes Framework (QOF) showed the results for practice management of patients with long-term conditions were good.
• Records showed that all relevant staff were now up to date with infection control training and fire safety training.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.
• The practice had made improvements to governance arrangements.
• The practice had systems and processes for learning, continuous improvement and innovation.

The areas where the provider should make improvements are:

• Continue with plans to improve the practice environment. For example, replacing stained and / or damaged carpets.
• Provide non-clinical staff with awareness training relevant to their role in the identification and management of patients with severe infections.
• Repair the hearing loop available at the reception desk.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Mary’s Medical Centre on 17 October 2017. The overall rating for the practice was requires improvement.

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

• There was an effective system for reporting and recording significant events.
• There were systems, processes and practices to help keep patients safe and safeguarded from abuse.
• The practice was unable to demonstrate they always followed national guidance on infection prevention and control.
• The arrangements for managing medicines did not always keep patients safe.
• Risks to patients, staff and visitors were not always assessed and managed in an effective and timely manner.
• Staff assessed needs and delivered care in line with current evidence based guidance.
• Data from the Quality and Outcomes Framework (QOF) showed the results for practice management of patients with long-term conditions were good.
• The practice was unable to demonstrate that all staff were up to date with essential training.
• The practice was unable to demonstrate they had a reliable system that managed test results and other incoming correspondence in a timely manner.
• 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.
• Patients said they were able to book an appointment that suited their needs. Pre-bookable, on the day appointments, home visits and a telephone consultation service were available. Urgent appointments for those with enhanced needs were also provided the same day.
• The practice was equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. However, governance arrangements were not always effectively implemented.
• The practice gathered feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.
• The practice did not have an effective system for managing notifiable safety incidents.
• There was a focus on continuous learning and improvement at all levels.

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.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are;

• Include all clinical equipment in checking to help ensure it is working properly.
• Continue to identify patients who are also carers to help ensure they are offered appropriate support.

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’s Medical Centre on 21 and 28 April 2015. Breaches of the legal requirements were found. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breaches.

We undertook this focussed inspection on 16 February 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting ‘all reports’ link for St Mary’s Medical Centre on our website at www.cqc.org.uk.

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 of St Mary’s Medical Centre on 21 and 28 April 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be good for providing caring and responsive services. It required improvement for providing safe, effective and well-led services which has led to this rating being applied to all patient population groups; older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored and appropriately reviewed. However, the practice was unable to demonstrate that they always responded to identified risks or that there were systems to adequately identify and reduce risk.
• Patient’s needs were assessed and care was planned and delivered following best practice guidance. However, the practice was unable to demonstrate they had an effective system to help ensure governance documents were kept up to date.
• Staff had received training appropriate to their roles and any further training needs had been identified and training planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment that suited their needs and that there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by management. However, operational difficulties existed due to the complex nature of premises ownership and were exacerbated by coordination difficulties between the practice’s partners.
• The practice acted on feedback from staff and patients. However, there was no patient participation group at St Mary’s Medical Centre.

There were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are;

• Ensure consistency when carrying out patients’ medicines reviews.
• Ensure consistency when carrying out discharge reviews and risk assessments of children and other vulnerable patients who attend accident and emergency.
• Ensure national guidance on infection control are followed and consider how deficiencies identified within the practice infection control audit are addressed.
• Ensure that emergency medicines are kept in date.
• Review the system to complete clinical audit cycles, in order to improve services and help ensure best practice guidance is followed.
• Ensure a system of governance for documentation review.
• Review involvement of staff from other service providers in the care and treatment of patients as well as the frequency and recording of multidisciplinary meetings.
• Improve the systems used to identify and reduce risk.

In addition the provider should;

• Improve the ways in which information about the practice and services provided are made available to patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice