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Inspection Summary


Overall summary & rating

Good

Updated 18 November 2019

We carried out an announced focused inspection at Chertsey Health Centre on 02 October 2019. This was to follow up on a breach of regulation found at our previous inspection on 07 March 2019, the practice was rated good overall and requires improvement for providing safe services. The details of these can be found by selecting the ‘all reports’ link for Chertsey Health Centre on our website at www.cqc.org.uk.

During the inspection we looked at the following key question

  • Is it safe?

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 the practice as good for providing safe services. The practice remains rated as good overall and good for all population groups.

We found significant improvements:

  • Health and safety risk assessments, including fire, COSHH and liquid nitrogen had been completed and action plans were in place to complete mitigating actions.
  • Infection control audits had been reviewed and action plans completed.
  • Staff immunisation status was monitored in line with current Public Health England guidance.
  • Arrangements were in place to ensure emergency medicines and equipment were regularly checked and fit for use.
  • Protocols for checking pathology results ensured that results were checked within an appropriate timescale reducing reliance on the laboratory to alert the practice to urgent results.
  • The practice had implemented formal clinical supervision arrangements for the nursing team, which included each nurse having a named GP clinical supervisor.
  • The recording of patient safety alerts included completed actions and where no action was required.
  • The process for obtaining and recording consent had been reviewed and improved to ensure where appropriate signed consent forms were attached to the clinical record.

The areas where the provider should make improvements are:

  • Continue to monitor and improve the recording of checks including blank prescription tracking and actions taken from safety alerts.

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

Inspection areas

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good