4 October 2023
During a routine inspection
We carried out an announced comprehensive at St Andrews Medical Practice on 27 September and 4 October 2023. Overall, the practice is rated as good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Requires improvement
Well-led - Good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Andrews Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection as part of our programme of inspecting locations that had been inspected as part our first phase of inspections using our current methodology.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This 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.
- A site visit.
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 established systems and processes that kept patients safe and protected them from avoidable harm.
- Patients received care and treatment that met their needs, however clinical searches we conducted showed that not all long-term conditions reviews were being carried out according to national guidelines.
- The practice used clinical and quality improvement audits to improve patient outcomes.
- Staff had the skills and knowledge to carry out their role effectively, however training records we viewed did not accurately reflect this.
- There were systems in place to manage and mitigate risk relating to the practice, but these not always utilised.
- There was compassionate and effective leadership at the practice.
- Governance systems relating to policies were not always reviewed regularly.
- The most recent National Patient Survey revealed that patients at the practice did not always access care and treatment in a timely way.
- The practice had an active patient participation group (PPG).
- There was evidence of continuous improvement and innovation at the practice.
We found two breaches of regulations. The provider must:
- Establish effective system and processes to ensure good governance in accordance with the fundamental standards of care.
- Act in an open and transparent way with relevant persons in relation to care and treatment provided to service users.
Whilst we found no additional breaches. The provider should
- Review practice management governance systems.
- Regularly review practice risk register to ensure full oversight and management of current and potential future risk.
- Employ systems to ensure clinical monitoring of patients is conducted according to national guidelines.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care