- GP practice
Archived: The Castlegate Surgery
All Inspections
9 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Castlegate Surgery on 28 May 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to;
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Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.
We undertook a desk based focused inspection of The Castlegate Surgery on 9 September 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting 'all reports' link for The Castlegate Surgery on our website at www.cqc.org.uk/
From the inspection on 28 May 2015, the practice were told they must:
- Ensure that all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess whether a DBS check is required.
We found that on the 9 September 2016 the practice now had appropriate processes and procedures in place.
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The practice had completed a risk assessment to determine which staff members required a DBS check.
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All nursing staff had been checked through the DBS process.
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A chaperone policy was in place to give guidance to staff when carrying out the role and to support clinical staff to recognise when a chaperone was required.
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The chaperone policy reflected the required risk assessment.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
28 May 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Castlegate Surgery on 28 May 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families with young children, working age people, those whose circumstances make them vulnerable and those suffering with mental health problems. It required improvement for providing safe services.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must:
- Ensure that all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess whether a DBS check is required.
In addition the provider should:
- Carry out the recommended actions from the legionella risk assessment to reduce the risk of infection to staff and patients.
- Ensure a chaperone policy is in place outlining the roles and responsibilities of staff carrying out this role.
- Ensure a system is in place for all staff to remain up to date with essential training such as safeguarding adults and vulnerable children?
- Carry out fire drills so all staff know what to do in the event of a fire.
- Implement a system to ensure that blank prescriptions are tracked through the practice and kept secure at all times, as required under the NHS Protect Guidance, August 2013.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice