Archived: Barnsley Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Barnsley Road Surgery on 14 February 2017. The overall rating for the practice was good with requires improvement in well-led. The full comprehensive report from 14 February 2017 can be found by selecting the ‘all reports’ link for Barnsley Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 4 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good with requires improvement for being well-led.

Our key findings were as follows:

• Some risks to patients were assessed and managed, others required review. For example, the practice could not provide a fire risk assessment and fire safety systems and procedures were not clear. An infection control audit had been completed although an action plan to address the areas identified for improvement had not been developed at the time of the inspection and there were shortfalls in the monitoring of some cleaning schedules.

• A system to track the use of blank prescriptions throughout the practice had been implemented. However, a record was not maintained when blank prescriptions were received into the practice.

• A monitoring log had been implemented to record medical indemnity cover and registration status with the professional bodies for all clinical staff.

• Actions taken after safety alerts were received by the practice had been documented.

• Staff had not received regular appraisal and some staff were overdue training updates. However, training had recently been arranged for staff and all staff had a date planned for an appraisal in October 2017.

• The procedure for monitoring the medical fridge temperatures had been reviewed and updated.

• The access walkway between the main building and the annex had been resurfaced.

• The system for recording verbal complaints had been reviewed and formalised.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Arrange for staff to receive regular appraisals as part of the appraisal system.

• Review practice policies to ensure they are current and reflect custom and practice.

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 Barnsley Road Surgery in November 2015 . The overall rating for the practice was inadequate and the practice was placed in special measures.

The full comprehensive report on the November 2015 inspection can be found by selecting the 'all reports' link on our website at www.cqc.org.uk.

The service was registered with us as a partnership but should have been registered as an individual. Immediate steps were taken by the provider to rectify the situation by submitting an application to deregister the service and register appropriately as an individual. During the inspection in November 2015 we identified regulatory breaches within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Care Quality Commission was unable to progress enforcement action against the provider, regarding these breaches, because the provider was not correctly registered.

Following the full comprehensive inspection on 14 February 2017, I am taking this practice out of special measures. This recognises the  improvements that have been made to the quality of care provided by the practice. We will be re-inspecting the practice to make sure that these improvements are maintained.

Our key findings across all the areas we inspected on 14 February 2017 were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• 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 individual complaints and concerns although there was no analysis of trends completed.
• 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.
• Risks to patients were assessed although there were shortfalls identified with regard to oversight and monitoring of systems, processes and procedures. For example, the practice did not have a system to monitor or track blank prescriptions within the practice, there was no documentation to confirm safety alerts had been actioned, there was no system to monitor clinical staffs’ registration with the professional bodies or medical indemnity cover had lapsed and there was no monitoring cleaning schedules had been completed.
• The practice had good facilities and was well equipped to treat patients and meet their needs with the exception of access between the main building and annex which required improvement for patients who may have mobility difficulties.
• There was a leadership structure and staff felt supported by management. The practice had recently developed a virtual patient participation group.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Implement a system to monitor and track blank prescriptions within the practice as outlined in NHS protect security of prescription guidance 2013..

• Ensure oversight, monitoring and risk assessment of practice systems, procedures and processes is implemented to ensure governance systems are current and remain effective.

• Ensure oversight and monitoring medical indemnity cover is in place and is adequate to cover the scope of work undertaken by all staff at the practice.

• Document the actions taken after safety alerts are received by the practice.

The areas where the provider should make improvements are:

• Arrange for all staff to receive regular appraisals as part of the appraisal system.

• Review access between the main building and the annex.

• Review the procedure for monitoring medical fridge temperatures to ensure safe storage of vaccines.

• Review and formalise the system for recording verbal complaints.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice