14 October 2020
During an inspection looking at part of the service
This service is rated as Good overall.
The service was previously inspected in May 2019 and was rated Good overall. They were rated as Good in Effective, Caring, Responsive and Well-led. However, it was rated as Requires Improvement in Safe.
The key question reviewed in this inspection Is now rated as follows:
Are services Safe? – Good
We carried out this announced focused inspection on 14 October 2020 to follow up on breaches we had identified at the last inspection. We had asked the provider to make improvements regarding:
- The provider could not confirm that staff who carried out chaperone duties had enhanced DBS checks completed.
- Full recruitment information was not available to demonstrate that safe recruitment practices had been carried out.
- Prescriptions for controlled drugs were not securely monitored.
We checked these areas as part of this focused inspection and found they had been resolved.
We found that:
- The provider had reviewed their procedure to ensure that all staff who have patient facing roles, which includes chaperones, were now required to have an Enhanced DBS check.
- We saw evidence to confirm all the appropriate recruitment information for all their current staff was now kept on site
- The practice manager drafted a new policy and set up a log for monitoring the use of controlled drugs prescriptions
There were a number of other issues from the previous report that we had said the provider should address. These were:
- Review the service quality improvement programme with a view to establishing an effective clinical audit process to review and improve patient outcomes.
- Review the process for recording and maintaining information related to Disclosure and Barring (DBS) checks carried out to confirm that appropriate DBS checks have been completed.
- Consider reviewing the performance of clinical staff to include a review of consultations, prescribing and referral decisions.
The provider reported that these had been addressed and provided evidence to support this. However, in the absence of an on-site inspection CQC were unable to review all actions. These matters do not affect the rating.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care