St James Surgery

Letter from the Chief Inspector of General Practice

In February 2016, during an announced comprehensive inspection of St James Surgery, we found issues relating to the practice’s control and assessment of its risk of legionella. Legionella is a harmful bacteria which can grow in some water systems, if the environmental conditions are right.

During the inspection, the practice was unable to produce a legionella risk assessment. This was in breach of the Health and Social Care Act 2008 Regulations. As a result the practice was rated as requires improvement for safe, and good for effective, caring, responsive and well led. The practice had an overall rating of good.

We carried out a focused inspection of the practice in September 2016. The provider sent us a risk assessment of their management of legionella. The practice also provided a written scheme evidencing the control for legionella. The written scheme of control explained how the risk of legionella would be managed within the practice.

We found the practice had made improvements since our last inspection in February 2016, and that it was now meeting the regulation relating to assessing the risk of legionella, which had previously been breached.

Following this focused inspection we have rated the practice as good for providing safe services. The overall rating for the practice remains good.

This report should be read in conjunction with the full inspection report of 9 February 2016. A copy of the full inspection report can be found at www.cqc.org.uk.

At this inspection we found that:

• The practice had instructed an independent company to assess the risk of legionella in the practice.
• Using the legionella risk assessment, completed by an independent company, the practice had produced a legionella risk assessment.

• Based on the legionella risk assessment, the practice had produced a written scheme of control for legionella.
• The practice was now able to provide evidence that it was following its own legionella risk assessment, and outlined any intended steps it would take to reduce the risk of legionella.

Systems were now in place to reduce and minimise the risk of legionella to both staff and patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St James Surgery on 9th February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area where the provider MUST make improvement:

• The practice must undertake a legionella risk assessment and implement any recommendations.

We saw two areas where the provider SHOULD make improvement:

• The practice should ensure their adult safeguarding policy included the contact details of who to contact if staff had concerns about a patient’s welfare.

• The practice should review their policy regarding electrical equipment testing which should include a risk assessment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice