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Reports


Review carried out on 5 December 2019

During an annual regulatory review

We reviewed the information available to us about Grange Street Surgery on 5 December 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 30 August 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Grange Street Surgery on 17 May 2017. We identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. Consequently the practice was rated as requires improvement for providing well-led services. The focused report from the 17 May 2017 inspection can be found by selecting the ‘all reports’ link for Grange Street Surgery on our website at www.cqc.org.uk.

After the focused inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- Good governance.

The areas identified as requiring improvement during our inspection in May 2017 were as follows:

  • Ensure plans of action to control and resolve the risks identified by the health and safety and Legionella risk assessments are completed.
  • Ensure that the Legionella management policy is adapted to the specific needs and requirements of the practice.
  • Ensure the governance arrangements in place provide staff with a clear understanding as to who is responsible for managing and responding to health and safety related issues and risks.

In addition, we told the provider they should:

  • Ensure that all clinical staff are participating in the practice’s programme of online essential training (e-learning).

We carried out an announced focused inspection on 30 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing well-led services.

On this inspection we found:

  • The governance arrangements at the practice supported the provision of a safe work place and patient environment.
  • Action was taken or in progress to respond to the risks identified and the improvements required by the health and safety review and Legionella risk assessment.
  • The Legionella management policy was specific to the needs and requirements of the practice.
  • Staff demonstrated a clear understanding as to who was responsible for managing and responding to health and safety related issues and risks.

Additionally where we previously told the practice they should make improvements our key finding was as follows:

  • Clinical staff were participating in the practice’s programme of online essential training (e-learning).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 17 May 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Grange Street Surgery on 30 September 2016. We identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided effective services. Consequently the practice was rated as requires improvement for providing effective services. The focused report from the 30 September 2016 inspection can be found by selecting the ‘all reports’ link for Grange Street Surgery on our website at www.cqc.org.uk.

After the focused inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- staffing.

The area identified as requiring improvement during our inspection in September 2016 was as follows:

  • Ensure that all staff employed are supported by a formal induction process, are receiving appropriate supervision and appraisal and completing the essential training relevant to their roles.

In addition, we told the provider they should:

  • Ensure a plan of action to control and resolve risks identified by the health and safety risk assessment is completed.
  • Ensure that a Legionella risk assessment is completed and that any issues identified are resolved.
  • Ensure that the Legionella management policy is adapted to the specific needs and requirements of the practice.

We carried out an announced focused inspection on 17 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection on 30 September 2016. This report covers our findings in relation to those requirements.

Our key findings on this focused inspection were that the practice had made some improvements since our previous inspection and were now meeting the regulation that had previously been breached. Consequently the practice is now rated as good for providing effective services.

However, the practice had not taken sufficient action in some areas identified on our previous inspection and were now in breach of legal requirements in those areas. On this inspection we found:

  • There was a formal and documented induction programme in place for newly appointed staff that ensured they had a comprehensive understanding of practice processes and procedures, including essential training requirements.
  • A system was in place to ensure staff completed the essential training relevant to their roles.
  • Sufficient systems were in place to ensure all staff received regular supervision and an appropriate appraisal of their skills, abilities and development requirements.
  • There were no action plans in place to control and resolve the risks identified by the health and safety and Legionella risk assessments.
  • The Legionella management policy was not adapted to the specific needs and requirements of the practice.
  • Staff were unclear as to who had responsibility for health and safety related issues at the practice, including managing and responding to the risk assessments.

The areas where the provider must make improvements are:

  • Ensure plans of action to control and resolve the risks identified by the health and safety and Legionella risk assessments are completed.
  • Ensure that the Legionella management policy is adapted to the specific needs and requirements of the practice.
  • Ensure the governance arrangements in place provide staff with a clear understanding as to who is responsible for managing and responding to health and safety related issues and risks.

In addition the provider should:

  • Ensure that all clinical staff are participating in the practice’s programme of online essential training (e-learning).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 30 September 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Grange Street Surgery on 30 September 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection in January 2016.

The areas identified as requiring improvement during our inspection in January 2016 were as follows:

  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection were fully implemented.
  • Ensure that health and safety and fire safety risk assessments were completed and that any issues identified were resolved.
  • Ensure a plan of action to control and resolve risks identified by the Legionella risk assessment was completed and that the Legionella Management policy was adapted to the specific needs and requirements of the practice.
  • Ensure that a business continuity plan was in place so that a service could be maintained in the event of a major incident.
  • Ensure that all staff employed were supported by a formal induction process, were receiving appropriate supervision and appraisal and completing the essential training relevant to their roles.
  • Ensure that the practice adhered to current guidance and national standards by including a defibrillator in its emergency equipment or completing a risk assessment as to why one was not required.
  • Ensure that at least one piece of photographic proof of identification was included in the personnel file of each member of staff.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Grange Street Surgery on our website at www.cqc.org.uk.

Our key findings on this focused inspection were that the practice had made some improvements since our previous inspection and were now meeting regulations that had previously been breached. However, the practice had not taken sufficient action in some areas identified on our previous inspection and were now in breach of legal requirements in those areas. On this inspection we found:

  • Infection control processes were in place and adhered to.
  • Systems were in place to ensure that staff employed at the practice received the appropriate recruitment checks.
  • There were sufficient systems and processes in place to monitor and address risks to patients and staff.
  • Appropriate arrangements were in place to deal with emergencies.
  • There were insufficient processes in place to ensure staff received a suitable induction, completed the essential training relevant to their roles and received an appropriate appraisal.

The areas where the provider must make improvements are:

  • Ensure that all staff employed are supported by a formal induction process, are receiving appropriate supervision and appraisal and completing the essential training relevant to their roles.

In addition the provider should:

  • Ensure a plan of action to control and resolve risks identified by the health and safety risk assessment is completed.
  • Ensure that a Legionella risk assessment is completed and that any issues identified are resolved.
  • Ensure that the Legionella Management policy is adapted to the specific needs and requirements of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 20 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Grange Street Surgery on 20 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.

  • 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 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 improvements are:

  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection are fully implemented.
  • Ensure that health and safety and fire safety risk assessments are completed and that any issues identified are resolved.
  • Ensure a plan of action to control and resolve risks identified by the Legionella risk assessment is completed and that the Legionella Management policy is adapted to the specific needs and requirements of the practice.
  • Ensure that a business continuity plan is in place so that a service could be maintained in the event of a major incident.

The areas where the provider should make improvements are:

  • Ensure that all staff employed are supported by a formal induction process, are receiving appropriate supervision and appraisal and completing the essential training relevant to their roles.
  • Ensure that the practice adheres to current guidance and national standards by including a defibrillator in its emergency equipment or completing a risk assessment as to why one is not required.
  • Ensure that at least one piece of photographic proof of identification is included in the personnel file of each member of staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice