Archived: The Chapel Street Surgery

Updated 28 January 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 4 February 2015. Breaches of legal requirements were found during that inspection within the safe, effective and well-led domains. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:

• Ensure that all staff are trained in the safeguarding of children and vulnerable adults.

• Ensure all staff are supported by means of receiving appraisals

• Ensure a programme of infection control processes is in place in order to ensure that policies and processes are effectively implemented.

• Ensure that risk assessment and monitoring processes effectively identify, assess and manage risks relating to health, safety and welfare of patients and staff

  Our previous report also highlighted areas where the practice should improve:-

• Establish a process to ensure more formal sharing of information and learning from incidents for all staff

We undertook this focused inspection on 24 November 2015 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.

This report should be read in conjunction with the last report from February 2015. Our key findings across the areas we inspected were as follows:-

• All staff had completed vulnerable adult and child safeguarding training to the appropriate level for their role and responsibilities.

• All staff had had a documented appraisal and were aware when the next was due.Training needs and opportunities were identified and acted upon.

• An infection control audit had been carried out and acted upon. The due date for the annual review of the audit was entered into the practice manager and infection control lead’s calendars and would trigger an alert.

• A risk assessment had been carried out in relation to fire safety

• A new system for recording significant events that identified a wider range of risk had been devised and was available on the computer hard drive.

• Significant events meetings were held every four to six weeks, decisions and learning were minuted, documented and disseminated to appropriate staff via their leads and via staff meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 28 January 2016

The practice is rated good for the care of people with long term conditions. At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As following this inspection, the practice is now rated as good for safety, effectiveness and being well-led, this population group is now also rated as good.

Updated 28 January 2016

The practice is rated good for the care families, children and young people. At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As following this inspection, the practice is now rated as good for safety, effectiveness and being well-led this population group is now also rated as good.

Updated 28 January 2016

The practice is rated good for the care of older people. At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As  following this inspection, the practice is now rated as good for safety, effectiveness and being well-led, this population group is now also rated as good.

Updated 28 January 2016

The practice is rated good for the care of working age people (including those recently retired and students). At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As following this inspection, the practice is now rated as good for safety, effectiveness and being well-led, this population group is now also rated as good.

Updated 28 January 2016

The practice is rated good for the care of people experiencing poor mental health (including people with dementia). At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As following this inspection, the practice is now rated as good for safety, effectiveness and being well-led, this population group is now also rated as good.

Updated 28 January 2016

The practice is rated good for the care of people whose circumstances make them vulnerable. At our inspection in February 2015 the provider was rated as requires improvement for safety, effectiveness and for being well-led. The concerns which led to these ratings applied to everyone using the practice, including this population group. As following this inspection, the practice is now rated as good for safety, effectiveness and being well-led, this population group is now also rated as good.