Archived: The Ship Street Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Ship Street Surgery on 9 December 2016. The practice was rated as requires improvement for providing well led services. The overall rating for the practice was good. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for The Ship Street Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 20 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 9 December 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of well led services. Overall the practice remains rated as good.

Our key findings were as follows:

• The practice had reviewed their governance arrangements to reduce risk and improve outcomes for patients.

• The practice had reviewed the monitoring and tracking of blank prescription forms through the practice. A new process was commenced on the day of the previous inspection and logs recording the issue and use of prescriptions were maintained.

• The practice had requested an external contractor to undertake a fire risk assessment. No high risk actions were identified and many medium and low risks were completed or timetabled for implementation.

• The practice had reviewed their systems for receiving and disseminating safety alerts received from the Medical and Healthcare Products Regulatory Agency. A dedicated email address for the alerts had been allocated to designated administration staff and was reviewed daily.

• Recruitment checks were undertaken and documented in line with practice policy.

• Practice data for 2016/17 showed improvement in patient outcomes for long term conditions and childhood vaccines. However, child vaccines were still below the national average and exception reporting for cancer related indicators had risen slightly.

However, there were areas where the practice should make improvements:

• Continue to monitor and improve rates for childhood vaccines and reduce exception reporting for cancer related indicators.

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 the Ship Street Surgery on 9 December 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 and an effective system in place for reporting and recording significant events.
• Risks to patients were mostly assessed and well managed. However, not all risks relating to tracking blank prescriptions, fire, disseminating patient safety alerts were fully assessed and mitigated. However, the practice took action to rectify these issues on the day of the inspection.
• 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.
• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were average compared to the national average for a number of clinical indicators.
• Most 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Most patients were positive about appointment availability. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a clear vision and strategy to deliver this vision.
• 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 areas where the provider must make improvement are:

• Consolidate systems for tracking blank prescriptions and ensuring that these are in line with national guidance.
• Implement further measures to assess risks relating to fire.
• Ensure that there are systems in place for disseminating and actioning patient safety alerts in the absence of the practice manager

The areas where the provider should make improvement are:

• Ensure recruitment checks are undertaken and documented in line with practice policy.
• Take further measures to monitor and improve rates for childhood immunisation, outcomes for people with long term conditions, and to reduce exception reporting.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice