We carried out a review of the data available to us about St Mary's 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 Mary's Surgery, you can give feedback on this service.
We carried out a desktop review of St Mary’s Surgery on 21 September 2016. This review was performed to check on the progress of actions taken following an inspection we made in April 2015. Following that inspection the provider sent us an action plan which detailed the steps they would take to meet their breach of regulation. During our latest desktop review on 21 September 2016 we found the provider had made the necessary improvements.
This report covers our findings in relation to the requirements and should be read in conjunction with the report published in August 2016. This can be done by selecting the 'all reports' link for the St Mary’s Surgery on our website at www.cqc.org.uk
Our key findings at this inspection were as follows:
The practice had improved the systems ensuring that risk assessments and mandatory training was managed effectively so that patient safety is promoted and any risks that could affect the quality of care are reduced. This included:
Fire safety had been strengthened so that patients had safe exits in the event of a fire.
The chaperone policy and associated procedures had been reviewed to ensure that appropriate vetting and training took place of any staff undertaking these duties, promoting patient safety.
Implementation of a system of risk assessment for any new staff to determine whether a Disclosure and Barring Service check was required according to their role and responsibilities.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Mary’s Surgery on 29 April 2015. This was the only location inspected. The provider currently has one other registered location, which is Bargate Medical Centre and also operates from a branch location at Telephone House Surgery and these premises were not inspected as part of this visit.
Overall the practice is rated as good.
Specifically we found the practice to be rated as good for providing caring, effective and well-led services. We found the service to be outstanding for providing a responsive service. We found the practice to require improvement for providing safe services.
The practice was rated as good for providing services to older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).
Our key findings were as follows:
We saw several areas of outstanding practice including:
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
In addition the provider should:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We were told that the practice would be meeting the requirements of the regulation by 31 January 2014. During our follow up inspections on the 8 May 2014, we found the provider was meeting the requirements of the regulation. On this occasion we did not speak with people who used the practice.
We spoke with 18 patients who were attending the main surgery during our inspection. We also spoke with two of the five GP partners, the practice manager, four practice nurses, and five administrative staff. Most patients were happy with the service they received from the surgery and the staff. They told us they could always get a same day emergency appointment when they needed one. Patients said there was adequate time at each consultation with diagnosis and treatment options fully discussed and explained to them. One said 'I am always able to ask questions, the doctors are good at explaining things'. Some patients felt they had to wait a long time after their appointment time, however, for other patients this was not a concern.
All patients said they were treated appropriately, with dignity and respect. All necessary recruitment and pre employment checks were in place and staff had completed induction and ongoing training. Staff were supported and received an appraisal each year. Arrangements were in place for staff to be able to recognise and report safeguarding children and vulnerable adults concerns. Infection control procedures were followed however, medicines storage was not secure.
The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of patients using the service and others. Patient's views were sought as part of the process to monitor the quality of the service provided.