We carried out an announced comprehensive inspection at the St Stephens House Surgery on 6 September 2016 and a focused follow up inspection on 17 August 2017. The practice was rated good overall. However, we found that the practice required improvement for the provision of safe services because breaches of regulation were identified. The full comprehensive report on the 6 September 2016 inspection can be found by selecting the ‘all reports’ link for St Stephens House Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused follow up inspection carried out on 6 February 2018. This was 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 August 2017. This report covers our findings in relation to those issues identified only.

Overall the practice is still rated as good and is now good in the safe domain.

Our key findings were as follows:

• The practice had incorporated a new on line training system that all staff had access to.

• Staff had received the appropriate training for their role.

• The practice manager had access to a training matrix and certificates of training were held in staff files.

• The GPs had quarterly training from the local clinical commissioning group.

• The practice was identifying potential areas of additional training support for non clinical staff in their everyday roles.

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 the St Stephens House Surgery on 6 September 2016. We found that the practice required improvement for the provision of safe services because breaches of regulation were identified. The full comprehensive report on the 6 September 2016 inspection can be found by selecting the ‘all reports’ link for St Stephens House Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 August 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 6 September 2016. This report covers our findings in relation to those issues identified.

The practice remains requires improvement for the provision of safe services. Overall the practice remains rated as good.

Our key findings were as follows:

• Safety and security of medicines including blank prescriptions had improved.

• Health and safety risks had been assessed and mitigated.

• Appropriate staffing checks were in place.

• Significant events were documented and there was evidence of learning .

At the previous inspection on 6 September we also said that the practice should:

• Review systems for recording staff training to ensure up to date information can be readily obtained. At this inspection we found that there was now a system to have oversight of training that staff had completed. However we found staff had not received training appropriate for their role.

• Monitor and ensure the appraisal system is fully embedded and delivered to all staff. During this inspection we saw that all staff had now received appraisals within the last 12 months

There was an area of practice where the provider must make improvements.

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.

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 Stephens House Surgery on 6 September 2016. Overall the practice is rated as Good.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• 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 not always assessed and well managed.
• 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 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 and complied with the requirements of the duty of candour.
• Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. This included how GPs and nurses listened to patients, treated them with care and concern, patient’s confidence and trust, access to the practice and the patients overall experience.

The areas where the provider must make improvement are:

• The provider must ensure that the medicines fridge is kept secure at all times.
• The provider must ensure that they monitor and maintain a record of the stock and use of the computer and hand written prescription pads used in the practice.
• The provider must ensure that they have a business continuity plan in place to maintain services to patients in the event of major incidents.
• The provider must ensure records for staff required by regulation are in place and maintained on record. This includes criminal records checks via the Disclosure and Barring Service and risk assessment of all staff in relation to unsupervised access to patients.
• The provider must ensure that the records of significant events are fully documented including the review of the event and the actions taken as a result of this review.
• The provider must ensure a health and safety assessment is put in place and this includes the risk of legionella.

The areas where the provider should make improvement are:

• The provider should review and continue to take action to identify carers who are patients at their practice.
• The provider should monitor and ensure the appraisal system is fully embedded and delivered to all staff.
• The provider should review the current system for recording staff training to ensure up to date information can be readily obtained.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice