20 December 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
This is a desk top review of evidence supplied by Dr C Dahs and Dr I P Humberstone, for areas within the key question Safe. This review was completed on 20 December 2016.
Upon review of the documentation provided by the practice, we found the practice to be good in providing safe services. Overall, the practice is rated as good.
The practice was previously inspected on 17 February 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated good overall. However, within the key question safe several areas were identified as requires improvement , as the practice was not meeting the legislation to meet Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe Care and Treatment.
At the inspection in February 2016 we found that the registered person did not assess and mitigate against risks as they had not risk assessed the need for Disclosure and Barring Service (DBS) checks for chaperones. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
Other areas identified where the practice was advised they should make improvements included:
- Reviewing or risk assessing arrangements for medical emergencies to ensure that equipment and medicines are in place.
- Reinstating Patient Participation Group (PPG) meetings, in order to identify and act on patients’ feedback and suggestions about the service.
- Conducting patient surveys as a means of obtaining patient feedback.
- Preparing a business continuity plan to be ready for any interruptions to service.
- Conducting regular fire evacuation drills in line with the fire risk assessment.
The practice supplied CQC with evidence of the action they would take after the inspection in February 2016. For this desk top review they provided a range of documentation which demonstrated they are now meeting the requirements of Regulation 12 Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice also demonstrated improvement in the other areas identified in the report from February 2016 which did not affect ratings. These improvements have been documented in the well-led section, showing how the practice has demonstrated continuous improvement since the inspection in February 2016.
The area where the practice should continue to make improvements are:
- Formalise the processes in place to protect patients by completing a written risk assessment for staff who act as chaperones who are not DBS checked, including updating the chaperone policy to reflect amended procedures.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice