The Bailey Practice

We previously carried out an announced comprehensive inspection of Bailey Practice on 24 October 2018. At the inspection, we rated the practice as good overall, but as requires improvement for providing safe services because:

• The practice had not completed a risk assessment supporting the decision to allow a receptionist to work whilst their Disclosure and Barring Service (DBS) check was pending.
• There was no process to carry out regular fire alarms tests and the fire extinguishers had not been checked.
• There was no evidence that some medical equipment had been calibrated to ensure it was in good working order.
• The practice did not have an effective failsafe system to ensure that cytology test results were received and acted upon and was not auditing inadequate cervical screening rates.
• In relation to monitoring a particular high-risk medicine, some patient test results were not documented within patients’ notes before prescribing.
• The practice had a system for recording receipt and acknowledgement of safety alerts. However, there was no documentation of what action was taken by the practice.

The full report of the October 2018 comprehensive inspection can be found by selecting the ‘all reports’ link for The Bailey Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection of The Bailey Practice on 12 March 2019 to check whether the practice was providing safe care.

We based our judgement of the quality of care at this service is 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.

At this focused inspection on 12 March 2019, we found that the provider had made improvements.

We have rated this practice as good overall.

We rated the practice as good for providing safe services because:

• Enhanced DBS checks had been completed for all non-clinical staff.
• Fire alarm tests were carried out and documented on a monthly basis and the fire extinguishers had been checked.
• Medical equipment had been calibrated and the practice had created an inventory of all equipment to monitor calibration due dates.
• The practice’s cytology failsafe log was updated and monitored on an ongoing basis and the practice was auditing inadequate cervical screening rates.
• A specific prescribing protocol for warfarin had been created and we saw patients’ test results were documented within patients’ notes on the clinical system.
• There was an effective system for safety alerts with any action taken by the practice documented.

We also found the practice had acted upon a suggested area of improvement from the previous inspection, relating to the identification of carers:

• The practice had been proactive in identifying patients who are carers, by sending letters to patients with chronic conditions, creating a new carer’s information board in the waiting area, and asking patients during consultations if they were cared for or had caring responsibilities.
• The practice provided information to carers about local support services and groups.
• At our previous inspection the practice had 18 patients coded on the clinical system as being carers; at this inspection, the practice had identified 55 patients as carers (1.4% of the practice population).
• Carers were offered annual influenza vaccines and 34 of 55 patients (62%) had received an influenza vaccination in the current programme.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care