The Care Quality Commission
  • Doctor
  • GP practice

Archived: High Oak Surgery Also known as QOF Doc Limited

Overall: Good read more about inspection ratings

120 High Street, Pensnett, Brierley Hill, West Midlands, DY5 4DS (01384) 366155

Provided and run by:
High Oak Surgery

Important: This service is now registered at a different address - see new profile

All Inspections

14 September 2016

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 High Oak Surgery on 1 September 2015. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified some areas where the provider must make improvements and additional areas where the provider should improve.

We undertook a focused inspection on 14 September 2016 to check that the provider had made improvements in line with our recommendations. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for High Oak Surgery on our website at www.cqc.org.uk.

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

  • We found that the practice had made many improvements with regards to infection control practices and record keeping. Improvements had been made across a number of further areas including prescription stationary monitoring and the practices staff filing system.
  • The practice followed guidance by Public Health England and kept adequate records to ensure effective management of the cold chain (for the safe storage and handling of vaccinations). Additionally, we saw that patient group directions (PGDs) well organised, current and signed by relevant staff members.
  • The practice had acted on the areas for improvement highlighted since our comprehensive inspection. For example: The practice implemented an effective failsafe system; for ensuring that test results had been received by the laboratory for every cervical screening sample sent by the practice.
  • The practice had clearly defined systems, processes and practices in place to keep people safe and safeguarded from abuse. Staff were aware of lead roles such as safeguarding and infection control leads.
  • The practice was proactive in identifying and managing significant events and learning was shared widely to support improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at High Oak Surgery on 1 September 2015. Overall the practice is rated as good.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed. However, we found that lessons learned were not always communicated widely enough to support improvement.
  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, we found some gaps in the management of infection control procedures, equipment checks and patient group directions (PGDs) were not in place for travel vaccinations administered by nurses.
  • Information about services and how to complain was available and easy to understand.
  • 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.

However there were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are:

  • Ensure that the management of infection control is robust and reflects national guidance, including adequate record keeping to support the management of infection control.
  • Ensure fridge temperatures are recorded correctly, in line with national guidance, to ensure robust maintenance of the cold chain.
  • Ensure patient group directions (PGDs) are in place for nurses who administer travel vaccines.

The areas where the provider should make improvement are :

  • Improve the management of staff files and ensure all content reflects employee history such as reference checks for staff.
  • Raise aware among staff of lead roles to enable them to seek appropriate support, for example in safeguarding and infection control.
  • Consider the effectiveness of current failsafe systems for cervical screening tests, ensure that test results are received by the laboratory for every sample sent by the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice