8th February 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Oundle on 7 June 2016. The overall rating for the practice was good, with requires improvement for the safe domain. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Oundle on our website at www.cqc.org.uk.
We undertook this follow-up focused inspection to check that they had followed their plan and to confirm that they now met legal requirements in relation to the breach identified in our previous inspection on 7 June 2016. This report only covers our findings in relation to those requirements.
Overall the practice is now rated as good. However, on the inspection on 7 June 2016, there were areas of practice where the provider needed to make improvements.
We found that the provider must:
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Ensure that staff who undertake chaperone duties have received a Disclosure and Barring Service (DBS) check or that a written risk assessment is in place.
In addition, we found that the provider should:
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Review the infection control policy and audit tool used ensuring that it is robust and meets the standards as outlined in The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance.
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Review the monitoring of the fridge temperatures ensuring that comments and actions as appropriate are taken should the temperature not be within the required range.
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Ensure that access to the dispensary is restricted to authorised staff only.
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Improve the record keeping of medicines stock levels in the dispensary.
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Ensure that all electric equipment is tested or risk assessed and is safe to use.
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Proactively identify and offer support to carers.
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Ensure that the risk assessment for legionella testing is completed and any actions taken.
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Improve the management oversight of significant events to ensure trends can be identified to encourage improvement.
At this inspection we found that
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The practice had Disclosure and Barring Service (DBS) checks in place for all chaperones.
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The infection control audit had been completed but could be improved further.
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Staff were regularly documenting fridge temperatures and action had been taken as required.
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The security measures for the dispensary had been reviewed and access was only given to authorised staff.
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Stock levels and expiry dates of medicines were checked and documented monthly.
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Electrical equipment had been tested.
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The practice had completed a legionella risk assessment.
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The practice had a proactive approach to the management, discussion and disseminationof significant events and had implemented a spreadsheet log.
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The practice identified 35 carers; this was less than 1% of the practice population. The practice recognised this was low, but also recognised that they had a lower number of older patients. The practice identified carers at registration, as well as during appointments for those being cared for. The practice had been proactive in using the carer templates on the clinical system and invited carers to receive a yearly flu injection and signposted them to local groups. The practice had information in the waiting area for carers and leaflets, including information on support groups.
However, the area where the practice should make improvements are:
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The practice should implement a system to mitigate the risks of legionella disease by monitoring the water temperature regularly.
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The practice should further improve the management of infection control b
Therefore, practice is now rated as good in the safe domain, and good overall.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice