15 June 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Drs Vitty, Pfeiffer and Berni on 10 February 2016. Breaches of legal requirements were found. We found breaches of four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the regulations). Warning Notices were issued in respect of Regulation 12 and Regulation 17 of the regulations. Requirement Notices were issued in respect of Regulations 18 and 19 of the regulations. The provider was required to make improvements and to submit an action plan detailing how they would make those improvements by 27 May 2016.
This focussed inspection on 15 June 2016 was to check that improvements required had been implemented and that the terms of each Warning Notice and the Requirment Notices had been met.
This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Drs Vitty, Pfeiffer and Berni on our website at www.cqc.org.uk.
The reference to the practice throughout this report refers to the practice now known as Drs Berni and Vitty, following the retirement of one of the GP partners, Dr Pfeiffer.
Our key findings across the areas we inspected were as follows:
The provider had met the requirements to improve.
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Improvements to protect patients from harm had been implemented. We found systems and processes in place that promoted patient safety. For example, recruitment checks had been reviewed and checks required on all staff were now in place. Essential training for staff had been delivered and a comprehensive training matrix was in use which identified when staff were due for follow-up or refresher training.
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Significant events were now being routinely reported, recorded and investigated. The subject of significant events was now a standing agenda item for practice meetings and clinical meetings. All staff had received training in significant events and understood that reporting and recording these promoted safety within the practice.
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Improvements to the practice treatment and consulting rooms had been made to enable the practice to better comply with infection control standards. All rooms and the patient waiting and reception areas were fitted with sealed flooring; all consulting and treatment rooms were fitted with compliant sinks. Privacy curtains that were disposable were fitted round all examination couches. We saw that cleaning schedules were in place for all areas of the practice and the standard of cleaning was reviewed on a daily basis by the infection control lead or the appointed deputy.
- 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 been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
- 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.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice