The Nunhead Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of The Nunhead Surgery on 28 January 2016 where the practice was rated Good overall. However, breaches of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified and we rated the practice as requires improvement for providing safe services.

The specific concerns in the previous inspection related to safety were:

• Not all staff had received the appropriate level of safeguarding, basic life support, infection control or fire safety training.

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).

We undertook this focussed inspection on 31 October 2016 to check that they had followed the action plan provided 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 The Nunhead Surgery 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 services.

Our key findings across all the areas we inspected were as follows:

• All staff had completed appropriate fire safety, safeguarding and infection control training. Two members of non-clinical staff had not completed basic life support training within the previous 12 months and the practice’s training schedule indicated that this training would be completed every 18 months for clinical staff and every three years for non-clinical.

The areas where the provider should make improvement are:

• Ensure that all staff complete annual basic life support training in accordance with current legislation and guidance.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Nunhead Surgery on 28 January 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients were assessed and well managed. However the practice’s systems and processes in respect of staff training were not robust enough to ensure patient safety.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand.

• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• The provider was aware of and complied with the requirements of the Duty of Candour.

  The areas where the provider must make improvement are

• Ensure that all staff have the appropriate mandatory training including safeguarding, infection control, fire safety and basic life support in accordance with current guidelines.

The areas where the provider should make improvement are:

• Consider undertaking an annual appraisal for all salaried GPs.

• Consider implementing the actions outlined in the practice’s legionella risk assessment.

• Ensure that no staff undertake chaperoning duties in the future unless the practice has completed a DBS check for the staff member or documented risk assessment regarding the necessity of a DBS certificate.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice