Updated 18 August 2016
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of the practice on 22 September 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(1)(2)(a)(b)(d)(f) Safe care and treatment and regulation 19(1)(b)(2)(a)(3) Fit and proper persons employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook this desk-based focussed inspection on 3 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Ebenezer Timeyin on our website at www.cqc.org.uk.
Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe and effective services, however they were rated as requires improvement for well-led services. As the practice was now found to be good for safe and effective services, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).
Our key findings across all the areas we inspected were as follows:
- Risks to patients were assessed and well-managed, including those related to fire, health and safety and responding to emergencies.
- Recruitment arrangements were robust including those for locum staff.
- Staff had received mandatory training and update training to be able to carry out their roles effectively, with the exception of safeguarding children’s training for all staff.
- The practice had a number of updated policies and procedures to govern activity.
- The practice had sought feedback from patients and had an active Patient Participation Group (PPG).
However there were areas of practice where the provider should make improvements:
- Ensure that there are systems in place to monitor and improve the quality and effectiveness of the service, including a clinical audit plan and systems to maintain medical and consultation records in line with guidance.
- Ensure that the practice carries out fire drills in line with the practice’s fire policy and completes all actions identified in the fire risk assessment.
- Ensure all staff have access to mandatory safeguarding children’s training in line with national recommendations and guidance.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice