Letter from the Chief Inspector of General Practice
This practice is rated as Requires Improvement overall.
(At the previous inspection on the 21 October 2015 the practice was rated as Good overall with requires improvement for the domain of safe.)
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement.
People with long-term conditions – Requires Improvement.
Families, children and young people – Requires Improvement.
Working age people (including those recently retired and students – Requires Improvement.
People whose circumstances may make them vulnerable – Requires Improvement.
People experiencing poor mental health (including people with dementia) – Requires Improvement.
At the previous announced comprehensive inspection at Seymour Medical Centre on 21 October 2015 the overall rating for the practice was good with requires improvement for the safe domain. The full comprehensive report on the October 2015 inspection can be found by selecting the ‘all reports’ link for Seymour Medical Centre on our website at www.cqc.org.uk.
We carried out a inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider continues to meet the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
At this inspection we found:
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The staff had clear roles and responsibilities to support good governance and management. However, we found the provider had failed to meet the requirements made at the previous inspection on the 21 October 2015.
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The provider had failed to carry out a review of the risk assessment to assess and mitigate against the risk of fire dated 1 August 2014 and follow all of the recommendations made. This included the recommendation for an electrical installation check of the premises. The Electricity at Work Regulations 1989, states all commercial properties should be inspected and checked every five years.
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The practice had systems in place to keep patients safe and safeguarded from abuse.
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There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses.
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Clinicians assessed needs and delivered care and treatment in line with current legislation, standards, and guidance supported by clinical pathways and protocols.
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The practice routinely reviewed the effectiveness and appropriateness of the care provided, at the practice meetings.
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Staff had the skills, knowledge, and experience to carry out their roles.
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We spoke with 13 patients who made positive comments about the practice and the GPs. We received 29 patient Care Quality Commission comment cards, 28 were positive about the service experienced.
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Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
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The practice involved patients, the public, staff and external partners to support the service.
The areas where the provider must make improvements as they are in breach of regulations;
The areas where the provider should make improvements are:
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The provider should review the Green Book to ensure they are following the guidance regarding staff immunisations. (The Green book is issued by Public Health England and contains the latest information on vaccines and vaccination procedures, for vaccine preventable infectious diseases in the UK).
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The practice should review the waste management system in the patient’s toilet.
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The provider should review the premises to make sure it complies with the estates, facilities alert regarding window blinds with looped cords or chains. (REF: EAF/2010/007 Issued 8 July 2010).
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The provider should ensure that vaccines are consistently stored following Public Health England Protocol for ordering and storing and handling medication.
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The practice should review the practice list to ensure that carers are correctly identified and on the carers register.
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The provider should regularly review the patient feedback and where appropriate implement a action plan in response.
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The provider should carry out cinical audits in response to patient issues identified within the practice.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice