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Dr Poolo's Surgery - Rush Green Medical Centre Good

We are carrying out a review of quality at Dr Poolo's Surgery - Rush Green Medical Centre. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 23 September 2020 and 13 October 2020

During an inspection looking at part of the service

We carried out an GP focused inspection at Dr Poolo's Surgery - Rush Green Medical Centre on the 23 September 2020 and 13 October 2020 as part of our inspection programme.

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. Unless the report says otherwise, all information contained within this report was obtained remotely from the provider.

We previously inspected Dr Poolo's Surgery on 6 March 2017. At this time we rated the practice good in all key questions. Details of this report can be found by selecting the ‘all reports’ link for Dr Poolo's Surgery on our website at www.cqc.org.uk.

The focused inspection undertaken on 23 September and 13 October 2020 did not review the ratings for the key questions or for the practice overall as this was a focused inspection undertaken to assess whether the provider had taken action to address an area of serious risk highlighted to the Commission following the receipt of information from a coroner's report.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

At this focused inspection we found:

  • Clinical records were viewed not always completed in-depth, which meant the best treatment for patients was identified.
  • Medication reviews were not always undertaken in a timely manner.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Review carried out on 4 July 2019

During an annual regulatory review

We reviewed the information available to us about Dr Poolo's Surgery - Rush Green Medical Centre on 4 July 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 6 March 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 P and S Poologanathan on 15 March 2015. The overall rating for the practice was good, however we rated the practice as requires improvement for providing safe services based on our findings which included lack of infection control training and legionella testing. The full comprehensive report on the 18 March 2015 inspection can be found by selecting the ‘all reports’ link for Dr P and S Poologanthan’s surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 6 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 March 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection we found that the issues found during the previous inspection had been addressed. Therefore, the practice is now rated as good for providing safe services.

Our key findings across the areas we inspected for this focused inspection were as follows:

  • We found that the infection control lead had undertaken infection control training and audits were now carried out at six monthly intervals.

  • We saw that learning from significant events was shared with non-clinical staff during practice meetings.

  • Legionella testing was carried out by an external organisation and possible hazards identified had been actioned and appropriate records were maintained.

  • We found that all staff who acted as chaperones were suitably trained.

  • The practice nurse was aware of and could sufficiently articulate the Gillick competencies.

  • The practice had a fire risk assessment and carried out fire drills annually.

  • Clinical audits we looked at demonstrated that improvements had been made to ensure any negative results were addressed.

The area where the provider should make improvement is:

  • The practice should review their fire risk assessment to ensure it is detailed and reflective of the practice’s current arrangements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 18 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr P and S Poologanathan's practice on 18 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. The practice requires improvement for providing safe services. It was also good for providing services for older people, people with long term-conditions, families, children and young people, the working age (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • 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 proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

  • Ensure appropriate standards of cleanliness and hygiene in relation to the premises occupied for the purpose of carrying out the regulated activity are met. To ensure the leads for infection control undertake training in infection control and are able to provide advice on the practice infection control policy and carry out staff training. Undertake infection control audits at periodic intervals.

In addition the provider should:

  • Ensure learning is communicated to the wider reception team, not directly involved with a significant event and are given opportunities to raise an issue for consideration and share good practice at regular practice meetings.
  • Ensure non clinical staff who undertake formal chaperone activities are suitably trained.
  • Ensure a Legionella risk assessment is completed to reduce the risk of infection to staff and patients.
  • Ensure the monitoring of audit results to ensure any negative results are addressed.
  • Ensure a fire risk assessment is completed to maintain fire safety.
  • The practice nurse to be aware of the Gillick competencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice