We carried out a review of the data available to us about St Agnes Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Agnes Surgery, you can give feedback on this service.
We carried out an announced focused inspection at the St Agnes Surgery on 30 August 2016. This was to review the actions taken by the provider as a result of our issuing two legal requirements. In October 2015 the practice did not have safe systems in place for the safe management of medicines and appropriate risk assessments were not in place to ensure staff within the practice had received appropriate checks and up to date mandatory training.
Overall the practice has been rated as Good following our findings, with safe and well led now rated as good. This report should be read in conjunction with our report published on 4 February 2016 where the effective, responsive and caring domains were rated as Good. This can be done by selecting the 'all reports' link for St Agnes Surgery on our website at www.cqc.org.uk
Our key findings across all the areas we inspected were as follows:
New procedures following the national guidelines for storing and recording the use of blank prescriptions were in place to ensure national guidance is followed.
New arrangements for prescribing under Patient Group Directives had been put in place to ensure all were authorised for use in the practice.
We found all staff who acted as chaperones had been trained for the role and had received a disclosure and barring service check (DBS). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
New processes had been put in place to ensure recruitment arrangements included all the necessary employment checks for all staff.
The provider had put in place processes and records to demonstrate risks to health, safety and welfare of people are well managed in relation to calibration of equipment and the testing of electrical equipment.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at the St Agnes Surgery on 8 October 2015. Overall the practice is rated as requiring improvement.
Specifically, we found the practice to be good for providing, caring, effective and responsive services, but found the practice to require improvement for safe and well-led services.
Our key findings across all the areas we inspected 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, appropriately reviewed and addressed.
Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and 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 services and how to complain was available and easy to understand.
Patients said they found it easy to make an appointment with a named GP and that 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.
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
Review procedures for storing and recording blank prescriptions to ensure national guidance is followed
Review arrangements for prescribing under Patient Group Directions to ensure all are authorised for use in the practice.
Ensure recruitment arrangements include all necessary employment checks for all staff.
Ensure that there are risk assessments in place for all staff in roles deemed not to need a Disclosure and Barring Service check. Staff undertaking chaperone duties must have received (DBS) checks.
The provider must have an overview and records to support the systems and processes in place, that demonstrate risks to health, safety and welfare of people are well managed in relation to calibration of equipment and the testing of electrical equipment.
Importantly the provider should:
The GPs should share findings from their audits to improve upon the care provision.
Undertake individual staff appraisals for all staff.
Keep a written record of all complaints so that any trends can be identified and rectified.
Keep a risk log to identify safety issues within the practice, including activities relating to fire procedures.
Chief Inspector of General Practice
As part of our inspection, we also spoke with the registered manager, the deputy practice manager, reception team, GP's, pharmaceutical dispensing staff, the phlebotomist, nursing staff and representatives from the patient participation group (PPG).
We found, people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.
People experienced care, treatment and support that met their needs and protected their rights.
People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.
People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.
People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.
The provider had an effective system to regularly assess and monitor the quality of service that people receive. The provider also had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.