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Review carried out on 17 December 2019

During an annual regulatory review

We reviewed the information available to us about Oaklands on 17 December 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 11 July 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 Oaklands on 4 August 2015. The overall rating for the practice was requires improvement as the practice required improvement for providing safe and well led services. The full comprehensive report on the August 2015 inspection can be found by selecting the ‘all reports’ link for Oaklands on our website at www.cqc.org.uk.

This inspection was undertaken on 11 July 2017 and was an announced comprehensive inspection 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 4 August 2015. This report includes our findings in relation to those requirements.

Overall the practice is rated as good.

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

  • There were systems in place to reduce risks to patient safety, for example, equipment checks were carried out, there were systems to protect patients from the risks associated with insufficient staffing levels and to prevent the spread of infection.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff felt supported. They had access to training and development opportunities appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.
  • Services were planned and delivered to take into account the needs of different patient groups.
  • Access to the service was monitored to ensure it met the needs of patients.
  • There was a system in place to manage complaints.
  • There were systems in place to monitor and improve quality and identify risk.

The practice had made some improvements to meet legal requirements but there were still areas where the provider should make improvements including:

  • Introduce a system to allow the findings and actions arising from investigations into significant events to be consistently shared with staff. Record the action taken and date of review of all significant events in the significant event log to allow a comprehensive overview of issues arising and actions implemented.

  • Introduce a formal process to monitor cleaning standards.

  • Ensure in-house checks of the fire alarm and emergency lighting take place at the recommended frequencies.

  • An up to date risk assessment to identify and manage risks presented by Legionella should be put in place.

  • The procedure to follow when a patient presents as needing urgent medical attention should be reiterated to all staff.
  • Ensure staff recruitment records contain evidence of information having been gathered about any health conditions which are relevant (after reasonable adjustments) to the role the person was being employed to undertake.
  • Review the system to identify the training needs of staff.

  • Review system used to identify carers registered with the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 4 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Oaklands on 4 August 2015.

Overall the practice is rated requires improvement. Specifically we found that safe and well led required improvement.

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

  • Urgent appointments were available the same day but not necessarily with a GP of their choice.
  • The practice had hearing loops, easy read format information and translation facilities.
  • Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG).
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • There had not been any deep cleaning of the premises and consequently there were areas of the practice which fell below acceptable standards of cleanliness.

There were areas where the provider must make improvements.

Importantly the provider must:

  • Carry out a deep clean of the practice premises as soon as practical and maintain the level of cleanliness by having appropriate monitoring systems in place.
  • Update their infection control procedures and training for all staff.
  • Ensure that clinical waste facilities are in line with recommended guidance.
  • Dispose of any opened packets of dressings immediately and ensure equipment is adequately decontaminated and stored.

  • Review its governance arrangements to improve incident reporting and audits, risk management, staffing including training and appraisals.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice