Tattenhall Village Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Tattenhall Village Surgery on 7 February 2017. The overall rating for the practice was Good. However, the practice was rated as requires improvement for providing safe services. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for Tattenhall Village Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused review carried out on 4 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified at our previous inspection on 7 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 as good.

Our key findings were as follows:

• The provider had improved safety systems in place to ensure that staff recruitment checks, monitoring of medication fridge temperatures and safety checks of the premises promoted the health, safety and welfare of patients.

The following improvements to the service had also been made:

• A system had been put in place to ensure that fire drills occurred at the recommended frequencies.

• A system to monitor the allocation of blank prescriptions was in place.
• A formal structure of supervision had been put in place for the advanced nurse practitioner.

• A record of verbal complaints was being maintained.

• A disability access audit had been undertaken.

• The systems for gathering patient feedback had been improved with the establishment of a patient participation group.

• The disciplinary procedure had been revised.

The areas where the provider should make improvements are:

• Where no references can be obtained during the recruitment process, clearly record the reason for this.

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 Tattenhall Village Surgery Centre on 7 February 2017.

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 medicines management.

• Staff 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 and had received training 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 patient groups.

• Access to the service was monitored to ensure it met the needs of patients.

• There was a system in place to manage complaints.

• There were systems in place to monitor and improve quality and identify risk.

The areas where the provider must make improvements are:

• The provider must monitor the safety systems introduced during the inspection to ensure that staff recruitment, recording of fridge temperatures and safety checks of the premises promote the health, safety and welfare of patients.

The areas where the provider should make improvements are:

• A system should be put in place to ensure that health and safety checks of the premises and fire drills occur at the recommended frequencies

• The recently introduced system to monitor allocation of blank prescriptions should be reviewed to ensure it is operating safely.
• The advanced nurse practitioner should be provided with formal supervision.

• A record of verbal complaints should be maintained which would allow for patterns and trends to be easily identified.

• A disability access audit should be undertaken.

• The systems for gathering patient feedback should be reviewed to ensure that this information is routinely sought.

• The disciplinary procedure should be revised to include the agencies that may need to be notified following the investigation such as the Nursing and Midwifery Council or General Medical Council.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice