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Inspection Summary


Overall summary & rating

Good

Updated 21 April 2017

Letter from the Chief Inspector of General Practice

We carried out a desk-based focused review of Ashwell Surgery on 14 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 17 February 2016. During our inspection in February 2016 we identified regulatory breaches in relation to:

  • Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment
  • Regulation 17 HSCA (RA) Regulations 2014 good governance

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

  • Ensure staff that act as chaperones are risk assessed for the need of a Disclosure and Barring Check (DBS) and those that require one receive a DBS check.
  • Ensure that the healthcare assistant has patient specific instructions from a prescriber before administering medicines.
  • Ensure an appropriate system is implemented for the safe management of controlled drugs.

In addition, the practice were told they should:

  • Introduce a system to risk assess the need for a DBS check at recruitment and for long standing staff.
  • Complete the delivery of the appraisals for non- clinical staff and competency assessments for dispensary staff in line with the programme schedule; completion date 31 March 2016.
  • Carry out periodic fire drills.
  • Complete the revision of the business continuity plan.

Our focused review on 14 March 2017 showed that improvements had been made and our key findings across the areas we inspected were as follows:

  • Systems had been improved to ensure that all non-clinical staff roles had been risk assessed to determine if a Disclosure and Barring (DBS) check was required.
  • The practice had an appropriate system in place to ensure patient specific directions were approved by a prescriber prior to the health care assistant administering vaccines.
  • Systems had been improved to ensure patient identification was checked prior to the issuing of any controlled drugs.
  • The practice had an appraisal policy and procedure in place and all non-clinical staff members had received an appraisal within the last 12 months.
  • Fire drills were carried out on a regular basis and the practice maintained a record of this.
  • The practice had a business continuity plan in place in place for major incidents such as power failure or building damage.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 21 April 2017

At our comprehensive inspection on 17 February 2016, we identified breaches of legal requirements. Improvements were needed to processes and procedures to ensure the practice provided safe services.

Specifically, the practice did not have a risk assessment in place to determine if a Disclosure and Barring (DBS) check was required for non-clinical staff members, including those performing chaperone duties. The health care assistant administered vaccines without patient specific directions from a prescriber. The practice did not have a process in place to ensure patient identification was checked prior to the issuing of controlled drugs.

During our desk based focused review on 14 March 2017, we found the practice had taken action to improve and the practice is now rated as good for providing safe services.

  • Systems had been improved to ensure that all non-clinical staff roles had been risk assessed to determine if a Disclosure and Barring (DBS) check was required.
  • All staff acting as chaperones had received training and a DBS check.
  • The practice had an appropriate system in place to ensure patient specific directions were approved by a prescriber prior to the health care assistant administering vaccines.
  • Systems had been improved to ensure patient identification was checked prior to the issuing of any controlled drugs.
  • The practice had an appraisal policy and procedure in place and all non-clinical staff members had received an appraisal within the last 12 months.
  • Fire drills were carried out on a regular basis and the practice maintained a record of this.
  • The practice had a business continuity plan in place in place for major incidents such as power failure or building damage.

Effective

Good

Updated 13 June 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 13 June 2016

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey showed patients rated the practice higher than others for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 13 June 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. For example the practice had worked with the CCG to improve the community anticoagulation service which is a local service to monitor patients on blood thinning medication.

  • Patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.

  • The practice provided a community anticoagulation service. This is a local service for the monitoring of patients on blood thinning medication, for those patients that can attend the practice and for the housebound. This service allowed the patient to receive a local service in the practice or in their home without the need to attend a hospital clinic.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 13 June 2016

The practice is rated as good for being well-led.

  • Staff were clear about the practice vision and their responsibilities in relation to this.

  • There was a supportive leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.

  • There was a framework which supported the delivery of appropriate patient care. This included arrangements to monitor and improve quality and identify risk.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty.

    The practice had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.

  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

People with long term conditions

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of people with long-term conditions. We did not review any evidence during our desk based review to alter this rating.

Families, children and young people

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of families, children and young people. We did not review any evidence during our desk based review to alter this rating.

Older people

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of older people. We did not review any evidence during our desk based review to alter this rating.

Working age people (including those recently retired and students)

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of working age people (including those recently retired and students). We did not review any evidence during our desk based review to alter this rating.

People experiencing poor mental health (including people with dementia)

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of people experiencing poor mental health (including people with dementia). We did not review any evidence during our desk based review to alter this rating.

People whose circumstances may make them vulnerable

Good

Updated 21 April 2017

Following our comprehensive inspection on 17 February 2016 we rated the practice as good for the population group of people whose circumstances may make them vulnerable. We did not review any evidence during our desk based review to alter this rating.