12 October 2022
During an inspection looking at part of the service
We carried out an announced focused inspection at Merchiston Surgery between 10th and 12th October 2022 to follow up on the warning notice issued to the provider following our inspection in June 2022 in regard to a breach of Regulation 12; safe care and treatment.
This inspection was not rated therefore ratings following our last inspection in June 2022 remain the same;
Safe - Requires Improvement
Effective – Requires Improvement
Caring - Good
Responsive – Requires Improvement
Well-led – Requires Improvement
Following our previous inspection on 15 June 2022, the practice was rated Requires Improvement overall.
We also issued the provider with requirement notices for breaches of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, related to good governance and staffing.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Merchiston Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook a remote regulatory assessment to monitor the providers progress against their action plan to confirm that the practice had met the legal requirements in relation to the warning notice served at our previous inspection in June 2022.
How we carried out the inspection
This remote desk-based review included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We found that:
- The practice had made improvements to how it provided care. However, the practice had not ensured that all patients prescribed high risk medicines received appropriate monitoring in line with national guidelines.
- Patients with long-term conditions did not always receive effective care and treatment which met their needs, despite improvements made in this area.
- Patients summarising records were kept up to date.
We found breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to all patients.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
We will continue to monitor the providers action plan in regard to the regulatory notice and will report on progress when we next inspect and rate the service.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services