2 August 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Baguant and Partners on 7 December 2016. The overall rating for the practice was good. However, we identified a breach of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. Consequently the practice was rated as requires improvement for providing safe services. The full comprehensive report from the 7 December 2016 inspection can be found by selecting the ‘all reports’ link for Dr Baguant and Partners on our website at www.cqc.org.uk.
After the comprehensive 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 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014
- Safe care and treatment.
The area identified as requiring improvement during our inspection in December 2016 was as follows:
- Ensure a sufficient process is in place and adhered to for the appropriate management of clinical notifications, for example pathology test results.
In addition, we told the provider they should:
- Ensure that notices around the practice advising patients that chaperones are available are clearly visible.
- Take steps to ensure that hot water temperatures at the practice are kept within the required levels and a comprehensive water temperature checking process is in place.
- Ensure that the fire risk assessment document is located and available.
- Ensure that all staff employed are supported by receiving appropriate supervision and appraisal and are completing the essential training relevant to their roles, including safeguarding and infection prevention and control training.
- Continue to identify and support carers in its patient population.
- Ensure the practice’s area of below average Quality and Outcomes Framework (QOF) performance for diabetes related indicators is improved.
We carried out an announced focused inspection on 2 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 7 December 2016. 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 safe services.
On this inspection we found:
- A sufficient process was in place and adhered to for the management and review of clinical notifications received from secondary care services, specifically pathology test results.
Additionally where we previously told the practice they should make improvements our key findings were as follows:
- Notices around the practice advising patients that chaperones were available were clearly visible.
- All staff had completed adult and child safeguarding and infection prevention and control training within the required timescales.
- An up to date and fully completed fire risk assessment was available.
- Water temperature checks were completed and recorded. Although many recorded water temperatures were above or below the required levels the appropriate investigations as to the causes of this had been completed and work was planned to rectify the situation in the near future.
- A programme was in place to ensure all staff received an appraisal on an annual basis and this was on schedule. We found that all non-clinical and nursing staff, including those previously overdue their annual appraisals had received a fully documented appraisal between November 2016 and July 2017.
- Through implementing a new protocol and coordinated practice wide approach, the practice had improved its Quality and Outcomes Framework (QOF) performance for diabetes related indicators. (QOF is a system intended to improve the quality of general practice and reward good practice). Figures provided by the practice showed that from April 2017 to August 2017 the practice had achieved 68% of the total number of points available with seven full months of the year remaining. The senior staff we spoke with said the forecast was for the practice to considerably improve on its full year achievement of 81% in the 2015/2016 year and 83% in the 2016/2017 year.
- The practice had identified inaccuracies in the way it recorded (coded) the services it provided to carers. We saw the practice had completed a piece of work to investigate and resolve the issues which included updating its policy and developing a carers toolkit as a process guide for staff to follow. Several staff members completed a full review of the practice’s carers register (those patients on the practice list identified as carers) to ensure the coding for each individual adequately reflected the services offered to them. As of 2 August 2017 the practice had identified 204 patients on the practice list as carers. This was approximately 2.6% of the practice’s patient list. Of those, 186 (91%) had been invited for a health review in the past 12 months. This was a considerable improvement on the 32% invited for a health review in the 12 months up to our inspection in December 2016.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice