Holbrook Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 6 July 2016. Breaches of Regulatory requirements were found during that inspection within the safe and effective domains. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulatory responsibilities in relation to the following:

• Ensure fire drills are carried out in line with national guidelines.
• Ensure infection control systems are robust and the infection control audit action plan is fully implemented.
• Ensure that a system is put in place to monitor hand written and computer printed prescription pads and forms.
• Ensure medicines were stored securely.
• Ensure staff with unsupervised access to patients had undertaken a disclosure and barring service (DBS) check and the practice has a policy in place to set out how DBS are used and risk assessed in the practice.
• Ensure staff recruitment records contain the information as set out by regulation.
• Ensure written consent is obtained for minor surgery.

We undertook this focused inspection on 15 December 2016 to check that the provider had followed their action plan and to confirm that they now met regulatory requirements.

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 Holbrook Surgery on our website at www.cqc.org.uk.

This report should be read in conjunction with the last report published in September 2016.

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

• We saw evidence to confirm that fire drills had been undertaken.
• The infection control audit had been updated and the action plan completed. Systems were in place to demonstrate regular monitoring and testing of the hot water system following a legionella risk assessment.
• We saw evidence to demonstrate that the practice had a system for monitoring both hand written and computer generated prescriptions.
• The medicines fridges were locked and medicines stored securely.
• The practice had introduced a system of risk assessment to determine if staff required a DBS check. We saw evidence to demonstrate these checks were undertaken were needed.
• Recruitment records contained the information required by regulation.
• The practice minor surgery policy had been updated and consent was sought and recorded in line with national guidance.

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 Holbrook Surgery on 6 July 2016. Overall the practice is rated as requires improvement.

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 not always 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.

• Risks to patients were generally assessed and but not always well managed. For example the practice had not undertaken a fire drill since 2011 and a legionella risk assessment had not been undertaken.
• Not all staff with unsupervised access to patients had received a Disclosure and Barring Service (DBS) check and staff recruitment records were incomplete.
• Infection control systems did not ensure the practice had mitigated the risk of infection.

• Clinicians did not routinely obtain written consent for minor surgery.

We saw one area of outstanding practice:

• GP partners had shared personal contact details with patients receiving palliative care and their carers to ensure timely access to a doctor at weekends and evenings.

The areas where the provider must make improvement are:

• The provider must ensure fire drills are carried out in line with national guidelines.
• The provider must ensure infection control systems are robust and the infection control audit action plan is fully implemented.
• The provider must ensure that a system is put in place to monitor hand written and computer printed prescription pads and forms.
• The provider must ensure staff with unsupervised access to patients had undertaken a DBS check and the practice has a policy in place to set out how DBS are used and risk assessed in the practice.
• The provider must ensure staff recruitment records contain the information as set out by regulation.
• The provider must ensure written consent is obtained for minor surgery.

.

The areas where the provider should make improvement are:

• The provider should review their significant event records to ensure the dissemination of information to all staff is captured.
• The provider should review their complaints responses to ensure complainants are signposted to the next steps they can take if they are unhappy with the response from the provider.
• The provider should review their patient list to actively identify patients that have caring responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice