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Dr Kelly & Associates - London Wall Good

Inspection Summary


Overall summary & rating

Good

Updated 4 November 2020

This service is rated as Good overall.

The service was previously inspected in May 2019 and was rated Good overall. They were rated as Good in Effective, Caring, Responsive and Well-led. However, it was rated as Requires Improvement in Safe.

The key question reviewed in this inspection Is now rated as follows:

Are services Safe? – Good

We carried out this announced focused inspection on 14 October 2020 to follow up on breaches we had identified at the last inspection. We had asked the provider to make improvements regarding:

  • The provider could not confirm that staff who carried out chaperone duties had enhanced DBS checks completed.
  • Full recruitment information was not available to demonstrate that safe recruitment practices had been carried out.
  • Prescriptions for controlled drugs were not securely monitored.

We checked these areas as part of this focused inspection and found they had been resolved.

We found that:

  • The provider had reviewed their procedure to ensure that all staff who have patient facing roles, which includes chaperones, were now required to have an Enhanced DBS check.
  • We saw evidence to confirm all the appropriate recruitment information for all their current staff was now kept on site
  • The practice manager drafted a new policy and set up a log for monitoring the use of controlled drugs prescriptions

There were a number of other issues from the previous report that we had said the provider should address. These were:

  • Review the service quality improvement programme with a view to establishing an effective clinical audit process to review and improve patient outcomes.
  • Review the process for recording and maintaining information related to Disclosure and Barring (DBS) checks carried out to confirm that appropriate DBS checks have been completed.
  • Consider reviewing the performance of clinical staff to include a review of consultations, prescribing and referral decisions.

The provider reported that these had been addressed and provided evidence to support this. However, in the absence of an on-site inspection CQC were unable to review all actions. These matters do not affect the rating.

Dr Rosie Benneyworth BM BS BMedSci MRCGP


Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 4 November 2020

We rated safe as Good because:

We had previously carried out an announced comprehensive inspection on 16 May 2019. At the time of that inspection the service was not providing Safe services. We found the following:

  • The provider could not confirm that staff who carried out chaperone duties had enhanced DBS checks completed.
  • Full recruitment information was not available to demonstrate that safe recruitment practices had been carried out.
  • Prescriptions for controlled drugs were not securely monitored.

At the time of the inspection on 14 October 2020, these issues had been addressed.

Safety systems and processes

The service had systems to keep people safe.

  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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). The provider sent evidence to confirm that all of their staff who have patient facing roles, which includes chaperones, were now required to have an Enhanced DBS check. They said they had also changed their process and updated their procedures to include retaining a copy of all DBS certificates.

  • The provider told us following our last inspection they had reviewed and updated their Recruitment Policy. They sent us a copy of their policy and evidence that they had all the appropriate information on site for all their current staff. This included checking references, work history, identity and DBS documents for all staff.

  • At our previous inspection in May 2019 we found the service kept prescription stationery securely but did not have systems in place to monitor controlled drugs prescription stationery received and issued at the service. The practice manager set up a log for monitoring the use of controlled drugs prescriptions. A copy of the log was forwarded to us following the inspection. The provider has now sent us a copy of their new policy and informed us that all staff had been made aware of the new procedure. We saw completed copies of the log to evidence that it was now being used.

Effective

Good

Updated 4 November 2020

Caring

Good

Updated 4 November 2020

Responsive

Good

Updated 4 November 2020

Well-led

Good

Updated 4 November 2020