Updated 4 July 2016
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of this practice on 13 October 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 12 Safe care and treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 19 Fit and proper persons employed.
We undertook this focused inspection on 17 May 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. 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 The Tickhill and Colliery Medical Practice on our website at www.cqc.org.uk.
Overall the practice is rated as Good. Specifically,following the focused inspection we found the practice to be good for providing safe and well-led services.
Our key findings across all the areas we inspected were as follows:
- Systems and processes were in place to keep people safe. For example, the practice implemented a procedure to check all emergency drugs monthly and to record those medicines disposed of due to expiry dates. Staff who acted as chaperones had received training for the role in January 2016. Disclosure and barring service (DBS) checks were also completed for all staff and an annual infection prevention and control audit had been completed on 31 December 2015. We saw evidence that action was taken to address any improvements identified as a result.
- We reviewed two personnel files for staff starting at the practice in June 2016. We found appropriate recruitment checks had been undertaken.
- A fire risk assessment had been completed following our comprehensive inspection in October 2015 and we saw evidence actions identified were completed. Fire alarms were tested weekly and a fire evacuation drill was completed on 15 October 2015.
- The partners had reviewed the governance framework to support performance and deliver good quality patient care. We saw evidence that all of the clinical and non-clinical policies and procedures had been reviewed and were available to all staff via their desktop on the practice computer.
- The practice had established a programme of internal audit to monitor quality and to make improvements. We were shown the planned audit schedule for the next 12 months.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice