We carried out an announced focused inspection at Stovell House Surgery on 13 December 2018 to follow up on breaches of regulations.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 6 December 2017.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good for providing safe services.

We found that:

• 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.
• The practice acted on and learned from external safety events as well as patient and medicine safety alerts.
• The practice had emergency medicines to deal with a range of medical emergencies.
• The practice acted on the recommendations following the legionella risk assessment.
• Clinical audit had a positive impact on quality of care and outcomes for patients.
• Appropriate staff completed Mental Capacity Act training.
• Response letters for complaints had the information on where to go if patents were dissatisfied with the outcome of the investigation.
• Only 13% (five patients) of 39 patients with learning disability had their health checks since April 2018; the provider informed they had booked health check appointments for 21 patients with learning disability till March 2019.

Whilst we found no breaches of regulations, the provider should:

• Undertake health checks for all patients with a learning disability.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection October 2014 rated overall as Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Stovell House Surgery on 6 December 2017 as part of our regular inspection programme.

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; however the practice did not record all significant events.
• The practice did not have a system to manage medicines and safety alerts.
• 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 provider had not undertaken any completed clinical audits in the last two years.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the practice must make improvements are:

• Ensure there is a system in place to receive, act and monitor the implementation of medicines and safety alerts
• Ensure all significant events are recorded and discussed for staff learning.

The areas where the provider should make improvements are:

• Have all medicines available to deal with a range of medical emergencies.
• Act on recommendations from legionella risk assessment.
• Undertake completed cycle clinical audits.
• Appropriate staff undertake Mental Capacity Act training.
• Undertake health checks for all patients with a learning disability.
• Improve the identification of carers.
• In response letters for complaints have all the necessary information for patients.

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 Stovell House Surgery on 15 October 2014. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Cleanliness and infection control.

We undertook this focussed inspection on 22 September 2015 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Stovell House Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

• Systems and processes were in place to keep people safe. The practice had ensured the infection control lead had up to date training to support them to carry out all aspects this role effectively. The practice had ensured a programme of audit of infection control arrangements was in place to ensure that key policies and practices are being implemented appropriately.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of Stovell House Surgery on 15 October 2014.

We rated Stovell House Surgery overall as good. We rated it as good for four of the five questions we ask at inspection. We rated it as requires improvement for providing safe services. We rated it as good at providing services to the six population groups we report on at inspection.

Our key findings were as follows:

• The practice clinical team referenced published evidence based guidance and their local clinical commissioning group care pathways in the delivery of care and treatment, and in ensuring positive health outcomes for its patients
• The practice used the Quality and Outcomes framework to measure, monitor and improve performance; and was performing better when compared to other practices in the area and against national averages.
• The practice was responsive to people’s needs, including those of various groups of people in vulnerable circumstances
• The practice was well led, and had been a teaching practice for many years

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

Importantly, the provider must:

- ensure a programme of audit of infection control arrangements is in place to ensure that key policies and practices are being implemented appropriately

In addition, the provider should:

- ensure the practice manager receives annual appraisal in line with the practice policy.

- ensure the infection control lead has up to date training to support them to carry out all aspects this role effectively

- ensure chaperone training is provided to staff who carry out these duties to reinforce their understanding and support their performance of these roles.

- ensure medicines are appropriately stored in fridges with allowances made for particularly busy periods such as during seasonal flu vaccination.

- ensure that their recruitment policy is followed in the recruitment of new staff

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice