- GP practice
Rising Brook Surgery
All Inspections
17 January 2018
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 Rising Brook Surgery on 20 June 2016. The overall rating for the practice was good with requires improvement in providing safe services. We carried out a focused follow up inspection on 31 July 2017 and found there were ongoing issues in providing safe services. The practice remained rated as requires improvement for providing safe services. The full comprehensive report for the 20 June 2016 and the focused report for 31 July 2017 can be found by selecting the ‘all reports’ link for Rising Brook Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 17 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation 12 that we identified in our previous inspection on 31 July 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good and good for providing safe services for all population groups.
Our key findings were as follows:
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There was a formal system in place to share learning from significant events with all staff and an analysis of trends had been completed.
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A safe and effective system had been implemented to manage the GP workflow throughout the practice.
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Most staff had received recent training in basic life support. Training for all staff had been arranged for February 2018.
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The practice was working with the landlord to ensure that the fire risk, that had exceeded its specified five year duration, was updated. They were exploring training options to ensure there was a fire marshal within the practice.
However, there were also areas of practice where the provider should make improvements.
The provider should:
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Ensure that all staff attend and complete the basic life support training planned for February 2018.
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Continue to work with the landlord to ensure the fire risk assessment is updated and there is a trained fire marshal within the practice.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
31 July 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection at Rising Brook Surgery on 20 June 2016. The overall rating for the practice was good with requires improvement for providing safe services. The full comprehensive report on the 20 June 2016 inspection can be found by selecting the ‘all reports’ link for Rising Brook Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 31 July 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 20 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as good but remains requires improvement for providing safe services.
Our key findings were as follows:
- An annual analysis of significant events to identify common trends had been completed. However, there was no formal system in place to share learning with staff to maximise learning and help mitigate further errors.
- Staff and patients were protected from the risk of health care acquired infections.
- Most staff employed had received training in fire safety and basic life support. However, some of the GPs had still not completed basic life support training in line with national guidance.
- Recruitment checks for staff met legislative requirements.
- All of the necessary safety checks on the building had been completed and copies of records obtained.
- Systems for managing the GP workflow through the practice were not supported by adequate staff training, guidance or audit.
We also saw the provider had implemented the best practice recommendation we previously made at our inspection on 20 June 2016 in relation to providing an effective service:
- Full cycle clinical audits had been carried out to show improvements made had been effective.
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
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Ensure care and treatment is provided in a safe way to patients in particular:
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Implement a formal system to share learning from significant events and analysis of trends with staff to maximise learning and help mitigate further errors.
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Implement a safe and effective system to manage the GP workflow through the practice.
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Clinical staff must complete basic life support training in line with national guidance.
In addition the provider should:
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Continue to work with NHS Property Services to ensure that all safety risk assessments are up to date and dated to provide an audit trail of when risk has been reviewed.
At our previous inspection on 20 June 2016, we rated the practice as requires improvement for providing safe services. At this inspection we found not all GPs had received basic life support training in line with national guidance and a formal system to share learning from significant events and trends was not in place. In addition, systems for managing the GP’s workflow were not supported by adequate staff training, guidance or audit. Consequently, the practice is still rated as requires improvement for providing safe services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
20 June 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Rising Brook Surgery on 20 June 2016. Overall, the practice is rated as Good.
Our key findings across all the areas we inspected were as follows:
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Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses.
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Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
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The practice was aware of the needs of the local population and had tailored services to reflect this.
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Staff felt supported in their work. The practice had significantly invested in the staff team to develop their skills and knowledge to improve outcomes for patients. There was an ethos of developing the right skill mix which ensured access to the appropriate clinician.
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Risks to patients were not always assessed and well managed; there was a lack of immunisation status records for staff, incomplete recruitment checks and lack of overview of safety systems such as legionella checks and fire drills.
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Patients said they were treated with compassion, dignity and respect. The results from the GP Survey reflected these comments and showed patients responded positively to questions about their involvement in planning and making decisions about their care and treatment.
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Patients told us they could get an appointment when they needed one. Urgent appointments were available on the same day.
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Information about services and how to complain was available and easy to understand. The practice actively reviewed complaints and improvements were made to the quality of care as a result of complaints and concerns.
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The practice had good facilities and was well equipped to treat patients and meet their needs.
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There was a clear leadership structure and staff felt supported by the management team. The practice proactively sought feedback from staff and patients, which it acted on.
The areas where the provider must make improvement are:
The provider must:
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Ensure that staff and patients are protected from the risk of health care acquired infections.
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Ensure that all persons employed have timely access to training such as fire safety training and basic life support training.
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Ensure recruitment checks for staff meet legislative requirements.
In addition, the provider should:
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Carry out an annual analysis of significant events to identify any common trends, maximise learning and help mitigate further errors.
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Improve the number and quality of completed clinical audits to show where improvements made are implemented and monitored.
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Assure themselves that all of the necessary safety checks on the building are completed and copies of records obtained.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice