30 September 2015
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection on 7 October 2014. We found the practice was in breach of legal requirements. The breaches related to regulation 9 (Care and welfare) and 13 (Management of medicines) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponded to regulation 12 (Safe care and treatment) and regulation 15 (Premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches.
We undertook this focused inspection on 30 September 2015 to check that they had followed their plan and to confirm that they now met the 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 the 'all reports' link for Drs K Conod, S Caddy & S Garsed on our website at www.cqc.org.uk
Our key findings were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns such as safeguarding, and to report incidents, including significant events.
- Systems were in place to ensure the safe storage of vaccinations and patient samples.
- Infection control procedures were in place but systems to monitor and maintain standards should be improved.
- Emergency medicines and medical equipment were managed safely and staff were aware of their roles in the event of a medical emergency.
- Non clinical staff did not have a disclosure and barring service (DBS) check or risk assessment in place to determine if a DBS check was required.
- There were plans in place to ensure the practice could still operate in the event of a major incident and staff we spoke with were aware of the plans.
However, there were also areas of practice where the provider needs to make improvements.
In addition the provider should:
- Risk assess staff who do not have a disclosure and barring service (DBS) check in place.
- Develop robust system to monitor and maintain standards of cleanliness within the general environment and ensure all actions from the recent infection control audit are completed including infection control training for all staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice