23/08/2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced focused inspection at The Limes Surgery on 23 August 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 27 January 2016.
This report only covers our findings in relation to the areas requiring improvement as identified on inspection in January 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for The Limes Surgery on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in January 2016 were as follows:
- Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection were fully implemented.
- Ensure that all applicable staff received appropriate checks through DBS (Disclosure and Barring Service) and that the required information was available in respect of the relevant persons employed.
- Ensure that all staff employed were supported, receiving the appropriate appraisal and have documentary evidence of role specific training completed.
- Ensure an appropriate system was in place for the safe use and management of emergency medicines and prescription pads.
- Review and update procedures and guidance so they reflected current legislation and guidance.
- Introduce systems to alert the practice of emerging risks such as in infection control, arrangements to deal with emergencies, staff recruitment including DBS checks, staff appraisal and training.
- Should review and make improvements to the disabled patient toilet facilities provided in line with the requirements of the Equality Act 2010.
Our key findings on this focused inspection across the areas we inspected were as follows:
- Systems and processes were in place to assess the risk of and to detect, prevent and control the spread of infection. For example, the practice had introduced a new infection control audit template and were completing an audit on a regular basis.
- The practice had risk assessed the roles of all non-clinical staff and appropropriate checks had been undertaken through DBS where applicable.
- All staff had received an appraisal and the practice had an up-to-date training log in place for all staff which evidenced role specific training, such as safeguarding
- The practice had appropriate systems in place for the effective management of emergency medicines and prescriptions.
- Practice policies were specific, kept up-to-date and reflected current legislation and guidance.
- Systems to manage risks including recruitment, staff training, appraisals and dealing with emergencies were in place and found to be adequate.
- Steps had been taken to review and make improvements to the disabled patient toilet facilities. For example, an emergency call bell had been installed.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice