Chertsey Health Centre

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

We carried out an announced comprehensive inspection at Chertsey Health Centre on 7 March 2019 as part of our inspection programme.

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 and good for all population groups.

We found that:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have appropriate systems in place for the safe management of medicines.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Improve the system for reviewing pathology results to reduce reliance on the laboratory alerting the practice of urgent results.
• Improve the recording and monitoring of where palliative patients would prefer to die.
• Improve the recording patient safety alerts to include completed actions.
• Review formal clinical supervision for the nursing team.
• Improve the process for signed consent forms being attached to the clinical record.

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