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Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Ormskirk House Surgery on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Ormskirk House Surgery, you can give feedback on this service.

Review carried out on 24 May 2019

During an annual regulatory review

We reviewed the information available to us about Ormskirk House Surgery on 24 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 19 January 2017

During a routine inspection

We carried out an announced comprehensive inspection at Ormskirk House Surgery on the 22nd October 2015. The overall rating for the practice was good and Safe required improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Ormskirk House Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 19 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 22 October 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection.

  • They had provided fire risk assessments and environmental risk assessments with regular inspections carried out by their health and safety advisors. Staff had undertaken fire training.

  • They have implemented an audit sheet in each clinical room undertaken on a monthly basis in line with checking medication to ensure that no out of date stock was stored.

  • All training records had been reviewed to ensure that all staff had evidence of updated training relevant to their role. Training had been updated with safeguard training for all staff.

  • They had shared incidents of risk and complaints with all staff to help improve shared learning within the team.

  • The appointment system had been reviewed. They had increased more online bookable appointments and advertised online access and promote the service. They provided pre bookable appointments for two weeks in advance for GP’s and had a number of “on the day” appointments available for GP’s of choice.

  • Policies and procedures had been reviewed to include written guidance to cover ‘Business continuity plans’ and ‘Governance systems’ within the practice to help mitigate risks of health and safety within the practice.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 2015/20/10

During a routine inspection

We carried out an announced comprehensive inspection at Ormskirk House Surgery on the 22nd October 2015. Overall the practice is rated as good.

Our key findings were as follows:

  • Improvements were needed in regard to mitigating safety due to gaps in audits and records for safety checks for temperatures of refrigerators, emergency drugs and equipment, managing fire safety and emergency procedures.
  • Clinical staff regularly reviewed significant events although there was no formal system to share learning amongst the whole staff team to identify and learn from events.
  • The practice had a safeguard lead and staff had reported patients at risk. However, there were gaps in staff training where some staff had not received safeguard training for vulnerable adults.
  • The practice had good facilities in a purpose built building with disabled access and a lift to the second floor consulting rooms. The practice was clean and tidy.
  • The clinical staff proactively sought to educate patients to improve their lifestyles by regularly inviting patients for health assessments.
  • Patients spoke highly about the practice and the whole staff team. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had a Patient Participation Group. They made suggestions throughout the year to help improve the service provided by the practice.
  • Information about services and how to complain was available on the practice’s website, but not within the reception area. Complaint records had detailed information to show how they had been investigated.
  • Staff had delegated duties distributed amongst the team. However, the practice manager’s role was still developing and work was needed to develop a clear leadership structure. Staff felt supported by management and they felt that since the promotion of the practice manager the practice was developing in the right direction.

There were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve:

  • Ensure that health and safety arrangements including risks assessments are reviewed and accessible to all staff and state clearly what actions are in place to maintain people’s safety. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 12 Safe care and treatment 1)2)a)b)c)d)g)

Action the provider SHOULD take to improve:

  • To ensure safeguard training is available and provided for all staff in regard to vulnerable adults and children and ensure staff are updated in the level of training needed for their role.

  • To share all serious incidents of risk and complaints with all staff to help improve shared learning within the practice.
  • To develop risk assessments and guidance regarding the decision to not carry emergency drugs in GP bags and for not storing oxygen within the practice.
  • The systems in place for monitoring medicines including their storage and expiry dates of equipment should be improved to ensure continuous safety checks.
  • To review training records to ensure that all staff have evidence of updated training relevant to their role and patient needs.
  • Review processes for accessing appointments and practice waiting times for appointments.
  • To review policies and procedures to ensure necessary written guidance is in place to cover ‘Business continuity plans’ and ‘Governance systems’ within the practice to help mitigate risks of health and safety within the practice.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice