Archived: Lance Lane Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fiske and Partners on 3 December 2015 and at this time the practice was rated as good. However, breaches of legal requirements were also found relating to the safe recruitment of staff and the information held by the practice. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

• Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;

During the inspection there were also a number of areas that required improvement and we identified that the provider should make the following improvements:

• The process for recording significant events and incidents should be reviewed. Written records should show the full detail of each incident, what actions were taken and what learning took place to ensure the risks to patients is reduced.
• The practice should undertake a risk assessment for legionella.
• Safeguard training should be available and provided for all staff in regard to vulnerable adults and children relevant to levels needed to undertake their roles.
• Full and completed induction records should be available for the induction of new staff. Written records should be maintained to show that all staff had completed an annual appraisal that this is used to inform their learning and personal development.
• A documented audit trail of all complaints should be held including the decisions reached, actions taken and the learning that has taken place.
• Policies and procedures should be up to date, valid and with sufficient detail.

On the 22 August 2016 we carried out a focused desk top review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in December 2015. 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 Fiske and Partners on our website at www.cqc.org.uk.

The findings of this review were as follows:

• The practice had addressed all of the issues identified during the previous inspection.
• The process for recording significant events and incidents was reviewed after our inspection. A new policy was set up for staff and this included tools to use to improve the recording of significant events and the learning and actions that take place when such events have occurred.
• The practice manager submitted information to show that a risk assessment for legionella had taken place.
• Safeguard training was available and provided for all staff in regard to vulnerable adults and children relevant to levels needed to undertake their roles.
• The practice implemented new human resource management policies and procedures and these included a recruitment qualification checking list. The policy states that all new staff will have full and completed induction programmes with records to support this. There had been no recent staff recruitment since the last inspection but assurance was given that the new policies and procedures including improved information for staff will be maintained. All staff had completed an annual appraisal that has been to inform their learning and personal development.
• The practice developed a new complaints management policy with supporting complaints information for patients.
• The practice reviewed its policies and procedures to ensure they were up to date, valid and with sufficient detail.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice