03/02/2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Surgery on 23 March 2016. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for The Surgery on our website at www.cqc.org.uk.
At our previous inspection on 23 March 216 we rated the practice as ‘good’ overall but as ‘requires improvement’ for providing a safe service as we identified breaches of Regulations 16 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not have a robust system in place for recording, investigating and taking action in response to significant events. The procedures for managing complaints also required improvement to ensure; patients were provided with accessible and accurate information about how to make a complaint, that all complaints were fully investigated in a timely manner and action was taken to prevent a re-occurrence.
This inspection was a desk-based review carried out on 3 February 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified at our previous inspection. This report covers our findings in relation to that and additional improvements made since our last inspection.
The findings of this inspection were that the provider had taken action to meet the requirements of the last inspection and the service is now rated as good for providing safe services. Our key findings were as follows:
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The provider has taken action to review the processes in place for managing significant events. There is now a more robust system in place for recording, investigating and taking action in response to significant events and for oversight and review of events.
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The complaints procedure had been reviewed and updated. Information provided to patients had been reviewed to include details about the different options for making a complaint and the stages of this. Systems for the oversight of complaints had been introduced including ensuring appropriate timescales were in place for responding to complaints. Complaints were discussed at regular clinical meetings and a review of complaints was carried out on a bi-annual basis.
The provider had also made a number of improvements where we had identified these at our last inspection. These included;
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A risk assessment had been carried with regards to whether or not staff required a Disclosure and Barring Service (DBS) check linked to their roles and responsibilities.
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The process for referring patients to secondary care for tests or treatments had been reviewed. The provider had designated additional staffing to improve the efficiency of the referrals process.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice