27 June 2019 to 27 June 2019
During an inspection looking at part of the service
We carried out an announced focused inspection at Bolton House Surgery on 27 June 2019 to follow up on breaches of regulations found at our last inspection.
At the last inspection in September 2018 we rated the practice as requires improvement for providing safe services because:
The provider had not assessed the risks to the health and safety of service users of receiving the care or treatment and was not doing all that is reasonably practicable to mitigate any such risks. Specifically, the provider had not carried out a fire risk assessment of the premises since 2006 and there had not been a recent full rehearsal of the evacuation procedure or regular checks of fire alarms.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
Overall the practice continues to be rated as good, however it remains requires improvement in the safe domain.
Details of our findings
At this inspection we found:
- The provider had taken steps to address the breach of regulations and carried out a fire evacuation as part of staff training. The practice had also engaged an external contractor to complete a fire risk assessment of the premises. However, they had not reviewed the action plan generated by this assessment.
- The practice had reviewed and improved the system to ensure the ongoing registration of clinical staff was checked and regularly monitored. We looked at the files of three clinical staff and found each contained evidence of the current registration status of the staff member.
- The practice had reviewed and improved the identification of carers so that they could be offered appropriate support. We were told that the practice had introduced a text system (MJog) and used their waiting area TV screen for a carers awareness promotion. The practice had identified 113 carers, approximately 2% of the practice population compared to the figures of 31 carers, approximately 0.6% of the population at the last inspection in September 2018.
- The practice had improved the audit trail to demonstrate that the action and learning from complaints, significant events and informal meetings had been shared. We saw minutes of meetings that included discussions on complaints and significant events. Learning was documented and shared.
The areas where the provider must make improvements as they are in breach of regulations are:
• Ensure care and treatment is provided in a safe way to patients.
Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.