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Inspection carried out on 22 September 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Hollybrook Medical Centre on 26 January 2016. During that inspection we found that a robust system was not in place to check the expiry dates of medicines carried by GPs on home visits. Also, a risk assessment had not been completed for certain non-clinical staff who undertook chaperone duties, who had not received a disclosure and barring service check.

Overall the practice was rated as good with are services safe requiring improvement in view of the above.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 

Hollybrook Medical Centre 

on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice told us what action they had, and were taking to meet the legal requirement in relation to the breach.

We undertook a focused inspection on 22 September 2016 to check that the provider had completed the required action, and now met the legal requirements. 

We visited the practice as part of this inspection. 

This report covers our findings in relation to the requirement. 

This inspection found that the provider had taken appropriate action to meet the legal requirement.

  • An effective system was in place to check the expiry dates of medicines carried by GPs on home visits to ensure they were in date and appropriate to use.

  • All staff carrying out chaperone duties had received a disclosure and barring service check. (These checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with vulnerable children or adults).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 26 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hollybrook medical practice on 26 January 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and generally well managed, however, a thorough risk assessment had not been carried out in respect of using some non-clinical staff as chaperones in the absence of a DBS check.
  • Some medicines carried by GPs were found to be out of date.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients told us 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.
  • Routine appointments with a named GP were available but patients often had to wait longer to see their preferred GP. Urgent appointments were available the same day.
  • The practice had good facilities, including a dedicated baby changing room 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 had a development strategy which had been shared with staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 3 June 2014

During an inspection to make sure that the improvements required had been made

This inspection was carried out to see if improvements had been made following our inspection of 11 July 2013.

During this inspection, we spoke with the practice manager and three members of staff. We did not speak with patients using the service.

We found patients were protected from the risk of infection because appropriate guidance had been followed. The provider had information, resources and audits in place in relation to infection control, to minimise the risk of the spread of infections. Patients were cared for in a clean and hygienic environment.

Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We found medicines were stored safely. There was a system in place to ensure that stock was regularly checked and medicines had not expired.

We found patients were cared for, or supported by, suitably qualified, skilled and experienced staff. Healthcare professionals working with patients had the appropriate qualifications and registrations with their professional regulators. A system was in place to identify any issues in which a member of staff may present a risk to patients.

Inspection carried out on 11 July 2013

During a routine inspection

Patients told us they were treated with care and respect. One patient said they were very pleased with the service they received. Some patients told us they were not always able to see a GP when they wanted to, but others said this wasn’t a problem. The on line booking service worked well. However, one patient told us “It is difficult to get through by telephone to get appointments.” Another said they had telephoned that morning and being offered a same day appointment.

All patients except one told us they felt listened to and involved in their care. One patient said the GP always discussed their concerns and explained any treatment options. Another patient told us that they had asked to see a different GP, as they did not feel their concerns had been listened to.

Staff we spoke with knew what actions they should take if they had concerns that a patient or their relative was unsafe or at risk of abuse.

Appropriate systems were not in place to help prevent the spread and risk of infections. Out of date clinical supplies were found in treatment rooms, clinical waste waiting disposal was not stored securely, treatment rooms did not meet infection control requirements, and cleaning equipment was not used or stored correctly.

Risk assessments had not been completed for staff who had been employed prior the current recruitment checks being in place.

Patients were asked for their views about their care and treatment and they were acted upon.