Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Eastview Surgery on 19 November 2015. The overall rating for the practice was requires improvement and requirement notices were made as improvements were needed in safeguarding, suitability of the premises and to governance systems. The full comprehensive report on the November 2015 inspection can be found by selecting the ‘all reports’ link for Eastview Surgery on our website at www.cqc.org.uk.
This inspection was undertaken on 30 August 2017 and was an announced comprehensive inspection.
Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There were systems in place to reduce risks to patient safety, for example, equipment checks were carried out, there were systems to protect patients from the risks associated with insufficient staffing levels and to prevent the spread of infection.
- Staff were trained, understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
- Staff felt supported. They had access to training and development opportunities appropriate to their roles.
- Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.
- Services were planned and delivered to take into account the needs of different and diverse patient groups.
- There was a system in place to manage complaints.
- There were systems in place to monitor and improve quality and identify risk.
- The premises and equipment were clean and suitable for use.
However, there are areas of practice where the provider should make improvements:
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Review the system for reviewing significant events and complaints on a regular basis in order to identify themes and trends and learn from these.
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Review the system for documenting action taken in response to patient safety alerts.
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Review policies and procedures to ensure they are up to date and specific to the practice.
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Implement a schedule for cleaning of clinical equipment and formal monitoring of the general housekeeping cleaning schedules.
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Implement a quality improvement programme which includes clinical audits being undertaken in response to local and national priorities. This should include infection prevention and control audits undertaken annually.
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Review communication with the patient participation group to actively encourage seeking feedback from this means.
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Review health and safety procedures to ensure that risks are assessed fully and control measures are in place and monitored.
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Implement a system for checking the validity of professional registrations for clinical staff
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Review and monitor the training plan for clinical and non-clinical staff to ensure all staff continue to be updated in their required training specific to their roles.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice