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Inspection carried out on 01/03/2017

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 The Portmill Surgery on 1 March 2017. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 22 June 2016. During our inspection in June 2016 we identified regulatory breaches in the safe care and treatment, staffing and governance at the practice.

This report only covers our findings in relation to the areas requiring improvement as identified on inspection in June 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for The Portmill Surgery on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in June 2016 were as follows:

  • Ensure an appropriate system is in place for the safe use of prescription pads, and the management of medicines, including those used in an emergency.
  • Ensure a Legionalla risk assessment is completed by a person competent to carry out the task. Implement any action required following the completion of the risk assessment and complete water temperature checks.
  • Complete an assessment on the control of substances hazardous to health.
  • Ensure that all staff employed are receiving an appraisal and essential training relevant to their role.
  • Ensure an accessible and robust system is in place for receiving and responding to complaints.
  • Create and maintain a record of fire alarm tests and fire drills carried out at the premises.

Our focused inspection on 1 March 2017 showed that improvements had been made and our key findings across the areas we inspected were as follows:

  • The practice had an appropriate system in place for the safe use and management of medicines, including those used in an emergency. Prescription pads were securely stored and an effective system was in place to monitor their use.
  • A legionella risk assessment had been completed by an external company and all of the required work and checks had been managed appropriately.
  • The practice had completed an assessment on the control of substances hazardous to health.
  • All staff members had completed essential training relevant to their role and had received an appraisal.
  • The practice had an effective system in place for receiving and responding to complaints, which was in line with national guidance.
  • Fire alarm tests and fire drills were carried out on a regular basis and the practice and landlord maintained a record of this.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 22 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Portmill Surgery on 22 June 2016. Overall the practice is rated as requires improvement.

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.
  • Improvements were made to the quality of care as a result of complaints and concerns. However, information about how to complain was not easily available.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 improvements are:

  • Ensure an appropriate and robust system is in place for the safe use of prescription pads, and the management of medicines, including those used in an emergency.
  • Ensure a Legionalla risk assessment is completed by a person competent to carry out the task. Implement any action required following the completion of the risk assessment and complete water temperature checks.
  • Complete an assessment on the control of substances hazardous to health.
  • Ensure that all staff employed are receiving an appraisal and essential training relevant to their role.
  • Ensure an accessible and robust system is in place for receiving and responding to complaints.
  • Create and maintain a record of fire alarm tests and fire drills carried out at the premises.

The area where the provider should make improvements is:

  • Keep and maintain a copy of the practice’s business continuity plan off the premises.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice