14 July 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
The practice was rated good overall and is now rated good for providing safe services.
We carried out an announced comprehensive inspection of this practice on 22 March 2016. Breaches of legal requirements were found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 14 July 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.
During our previous inspection on 22 March 2016 we found the following areas where the practice must improve:-
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Put arrangements in place to ensure the safe use of medicines.
Our previous report also highlighted areas where the practice should improve:
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Undertake a formal, written risk assessment regarding the decision not to have a defibrillator on the practice premises.
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Develop an ongoing audit programme that demonstrates continuous improvements to patient care in a range of clinical areas. Ensure there are at least two cycles of a clinical audit.
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Ensure that higher levels of exception reporting for the quality and outcomes framework are kept under review.
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Hold regular meetings with the patient reference group and ensure feedback is sought on practice specific issues.
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Undertake pre-employment health checks for all new staff.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk
During this inspection we found:
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The practice had invested in new vaccine fridges and there was an updated cold chain policy which was adhered to.
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The practice had updated their prescription security protocol to include the security of prescriptions. There was a register of prescription ordering and distribution which included serial numbers of prescriptions issued.
We also found in relation to the areas where the practice should improve:
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The practice had taken the decision to have a defibrillator on the practice premises and this was in place.
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The practice had an active audit culture in place and had conducted a two cycle audit since our initial inspection.
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The practice provided us with minutes of meetings during which discussion relating to reducing exception reporting had taken place.
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The practice had introduced a protocol of undertaking pre-employment health checks for all new staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice