We carried out an announced review at St George's Medical Centre on 21 April 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective – Previously rated Good
Caring - Previously rated Good
Responsive - Previously rated Good
Well-led - Previously rated Good
Following our previous inspection on 21 October 2018 the practice was rated Good overall.
One patient population group in the Effective domain was rated as Requires Improvement for providing safe services to ‘Older People’, this was as a result of the care plans identified in Safe domain.
The Safe key question was rated as requires improvement due to concerns about the management significant events, care plans and hazards being identified during the October 2018 inspection.
We issued the provider with a requirement notice for breach of Regulation 12 (Safe care and treatment) and asked them for an action plan detailing what they would do to improve.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for https://www.cqc.org.uk/location/1-541783599/reportson our website at www.cqc.org.uk
Why we carried out this review
This review was a follow-up of information without undertaking a site visit inspection to follow up on:
- The original breach identified in Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.
- Care plans – as previously they were not clearly documented, and information was stored in various places within the IT system.
- The management of significant events – as the threshold needed to be lowered and learning cycles completed.
- Trip hazards that we identified in the waiting area and the use of incorrect waste bins in the consultations room.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we reviewed
- information from our ongoing monitoring of data about services and
- information from the provider and other organisations.
We have rated this practice as Good in the Safe key question and Good overall with the older people Population Group rated Good in effective / responsive.
We found that:
- A new process had been developed for managing significant events which included documenting and reviewing events. Learning and improvements cycles were also taking place.
- Care plan process had been updated and a new process implemented which included monitoring and reviewing all care plans. The practice also implemented care planning processes as part of Long-Term Condition (LTC) reviews. Care plans were directly inputted into the patient’s clinical record for coding.
- Clinical waste bins had been ordered and placed in all consultation rooms. The practice had also updated and completed their Infection Control action plan to reflect these changes.
- Trip hazards in the entrance and waiting area of the building had been resolved the day after the inspection with photographic evidence provided.
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