Archived: St Andrews Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 28 April 2016. Breaches of Regulatory requirements were found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulatory responsibilities in relation to the following:

• To ensure that the practice had a system for securing and tracking the use of prescription forms used by the practice.
• To ensure the practice had a system for addressing issues identified in the infection control audit.
• To ensure that the practice had in place a system that correctly monitored all significant events that occurred in the practice.

We undertook this focused inspection on 19 October 2016 to check that the provider had followed their action plan and to confirm that they now met regulatory requirements. This report only 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 St. Andrews Surgery on our website at www.cqc.org.uk.

This report should be read in conjunction with the last report published in July 2016. Our key findings across the areas we inspected were as follows:-

• We saw evidence that prescriptions forms were securely stored at all times and that there was an effective system in place that tracked these forms from entry into the practice to their subsequent use.
• We saw evidence that there was an effective system in place that recorded and monitored the actions taken to address issues found during infection control audits.
• We saw evidence that the practice had a system in place that recorded each significant event and monitored how this was progressed and discussed within the practice.

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 at St. Andrews Surgery on 28 April 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety; however systems in place for reporting and recording significant events required improvement.
• Risks to patients were assessed and managed although some shortfalls in relation to infection control and prescription form tracking required improvement.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Safe arrangements were in place for staff recruitment that protected patients from risks of harm.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Urgent appointments were usually available on the day they were requested, but some patients said that it was difficult to make an appointment.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

• The practice had administrative staff trained to take appropriate action on incoming clinical correspondence and redirect the workflow as appropriate. This saved on average 40 minutes of each GPs time each day. There were governance arrangements to oversee this work.

The areas where the provider must make improvement are:

• To maintain a recording system to track prescription forms.

• To review their infection control policy to ensure that an action plan is in place to rectify any issues found on inspection audits.

• To review their significant event analysis procedure to ensure that the documentation of these issues is complete.

The area where the provider should make improvements is:

• To actively identify patients that have caring responsibilities within the patient list.

• To review how the practice could increase the uptake for childhood immunisations

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice