Background to this inspection
Updated
26 July 2021
The MacMillan surgery is located in Knowsley, Liverpool at:
St Chad's Centre
St Chad's Drive
Liverpool
Merseyside.
L32 8RE
The provider is Dr Kok Foon Thong who is registered with CQC to deliver the regulated activities; diagnostic and screening, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
The practice is situated within the Knowsley Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 6,000. This is part of a contract held with NHS England.
The MacMillan Surgery is part of a wider network of GP practices and is one of six practices which make up the Kirby Primary Care Network.
Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 98% white British.
There is a team of five GPs who provide cover at the practice. The practice has a team of three practice nurses. The GPs are supported at the practice by a team of reception and administration staff. The practice manager provides managerial oversight.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations.
Extended access is provided locally by PC 24 where late evening and weekend appointments are available.
The practice is on one level and is accessible via stairs and a lift. The facilities include toilets, waiting area, private consulting/treatment rooms. Car parking is available on site and a fee-paying car park nearby. The practice has good transport links.
There is a pharmacy located within the building. The building also contains a number of healthcare services, such as x-ray, midwifery, walk-in centre, community matron, Macmillan service, school nursing and Podiatry.
Updated
26 July 2021
Following our previous inspection on 25 September 2019, the practice was rated good overall and for all population groups but was rated requires improvement for providing safe services.
We carried out an announced desktop review of The MacMillan Surgery on 30 June 2021.
Overall, the practice remained rated as Good.
The rating for the key question followed up was:
Safe - Good
The other key questions remain unchanged as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The MacMillan Surgery on our website at www.cqc.org.uk
Why we carried out this review
This review was a focussed review of information without undertaking a site visit. This was to follow up on the key question - Safe.
We reviewed the breaches in the Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed. The regulation was not being met because: the system for ensuring that all the required documentation to demonstrate safe recruitment and ongoing staff suitability was not in place.
We reviewed breaches in the Regulations 15 HSCA (RA) Regulations 2014 Premises and Equipment. The regulation was not being met because: The provider did not have robust systems in place to assess the security of the premises and equipment and to identify health and safety risks or to take action to address them. Consulting rooms and the back-office areas were not secure.
We also reviewed the areas where the provider should make improvements by:
- Providing reception staff with formal training for identifying and responding to patients with suspected sepsis.
- Monitoring processes for checking uncollected medicine prescriptions.
- Increasing the frequency of high-risk medicines searches to ensure the required patient health checks were timely.
- Retaining training certificates to confirm the courses that have been completed.
- Formalising clinical reviews and recording clinical staff supervision and monitoring.
- Reviewing systems used to encourage patients to cooperate with health screening and childhood immunisation vaccine initiatives.
- Providing formal training for non-clinical staff in the Mental Health Capacity act 2005 and the Deprivation of Liberty Safeguards (DoLs).
- Offering personalised care plans to patients.
How we carried out the review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.
This review was carried out without visiting the practice. This was with consent from the provider and in line with all data protection and information governance requirements.
This included
- Conducting staff interviews using video conferencing
- Requesting evidence from the provider
- Reviewing action plans sent to us by the provider
Our findings
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 overall and Good for all population groups.
We found that:
The breach of regulation 19 HSCA (RA) had been addressed to ensure that all the information specified in Schedule 3 HSCA was readily available for each person employed. Evidence of pre-employment health checks and ongoing checks of registration were provided.
The breach of regulation 15 HSCA (RA) had been addressed to ensure consulting rooms were secure and all sensitive information and documents were kept securely in line with data protection requirements. Evidence that consulting rooms were kept locked as required and computer smart cards removed was provided. The security policies and procedure had been strengthened and smart lock and key systems had been installed. The provider monitored adherence to the policies and remedial action was taken as required.
- The provider had taken effective steps to ensure staff knew how to identify and respond to patients with suspected sepsis.
- The collection of prescriptions was now monitored.
- The frequency of high-risk medicine searches had been increased to monthly.
- Training certificates were retained and copies readily available for scrutiny.
- Processes were in place for recording formal clinical reviews concerning all levels of clinical and non-clinical staff.
- Evidence indicated that action taken in partnership with other members of the Primary Care Network were having a positive effect on the uptake of cervical screening and childhood immunisation.
- The provider was in the process of sourcing Mental Capacity Act and Deprivation of Liberty training for non-clinical staff.
- The provider confirmed that care plans were provided to patients with asthma as required.
We found no breaches of regulations.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care