This practice is rated as Good overall. (Previous published rating October 2017 – Requires Improvement)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Mendip Vale Medical Practice on 26, 27 and 28 June 2018. This inspection was to follow up the concerns we found at the previous inspection in August 2017. These areas of concern were relating to ensuring that appropriate disclosure and barring checks and training was in place for staff providing chaperone duties and there was proper and safe management of medicines including controlled medicines and prescription paper and pads. Also, the provider must have ensured that staff worked in accordance to the organisations policies and procedures in relation to significant event analysis, emergency medicines, complaints, medicines management and health and safety. In addition, the provider should have continued with the changes they were implementing for infection prevention, the immunisation status of staff, Control of Substances Hazardous to Health(COSHH), fire drills and checks on emergency equipment were sustained. Also, non-clinical staff responsible for telephone handling have the necessary training and guidance for the triage of patient's needs regarding the urgency of being seen by a clinician. The provider should have continued to notify the commission without delay any incidents of serious injury to a service user or events that may stop the service.
These concerns resulted in the practice being rated Requires Improvement overall, with the domains of Safe as Requires Improvement, Effective, Caring and Responsive as Good and Well Led as Inadequate.
At this inspection we found:
That the practice had responded and implemented a programme of improvement and the concerns previously found had been rectified.
We found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easier to use and reported that they could access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
- The provider should develop its systems of checks and recording information regarding staff vaccinations in accordance to Public Health England (PHE) guidance.
- The practice should strengthen their risk assessment processes for infection prevention and control regarding identified risks and the actions taken to mitigate risks.
- The practice should review the safety and security of the external storage of their clinical waste.
- The practice should review information available to patients regarding chaperone service and processes for offering a chaperone.
- The practice should continue with monitoring and respond accordingly to patient feedback in regard to the concerns about the difficulty in making an appointment and access to appointments.
- The practice should improve how it keeps patients informed about any delays in waiting for appointments.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.