We carried out an announced inspection at Barlby Surgery on 5 and 21 October 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Following our previous inspection on 28 February 2019, the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 12 Safe care and treatment.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Barlby Surgery on our website at www.cqc.org.uk.
Why we carried out this inspection
This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment.
At this inspection we covered the following key question:
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall. We rated the practice as Good for providing safe services.
We found that:
- The practice had demonstrated improvements compared to the previous inspection.
- Our clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including high-risk medicines.
- We found the prescription box for uncollected prescriptions was monitored effectively.
- We noted the system for checking single-use equipment and the doctors’ bag was operating effectively.
- Sepsis awareness had been discussed in the practice meetings, which included scenario based discussion and training.
- Blind loop cords were secured appropriately.
- We found the practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and records were maintained as intended.
- The practice had maintained a complaints log and all complaints were discussed and learning shared during team meetings at the practice and regional level.
Whilst we found no breaches of regulations, the provider should:
- Ensure that the newly written protocol for the safe and secure oversight of blank prescription management is embedded and appropriately reviewed to be assured that it is operating effectively.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care