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Inspection carried out on 5 October 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 on 29 September 2016 at The Bacon Lane Surgery. At that inspection the practice was rated good overall. However, we rated the practice as requires improvement for providing a safe service. This was because the practice could not demonstrate it assessed and managed risks safely.

The full comprehensive report of the 29 September 2016 inspection can be found by selecting the ‘all reports’ link for The Bacon Lane Surgery on our website at

This inspection was a focused inspection undertaken on 5 October 2017 to check that the practice had addressed the requirements identified in our previous inspection. This report covers our findings in relation to those requirements.

Overall the practice remains rated as good. Following this inspection, we have revised our rating for whether the practice is providing a safe service. The practice is now rated as good for providing a safe service.

Our key findings were as follows:

  • The practice had effective systems in place to assess and manage risks to patients and staff. The practice had developed a tailored health and safety policy. Fire safety and legionella risk assessments had been carried out by suitably qualified persons with clear recommendations for further action and monitoring.
  • The practice had implemented the recommendations arising from relevant risk assessments. The practice was document the health and safety related monitoring checks it routinely carried out.

At our previous inspection, we also noted that:

  • Consent was not always documented in patient notes for example when carrying out procedures such as joint injections. At this inspection, the practice showed us the patient consent form and information leaflet provided to patients undergoing joint injections. We reviewed a number of records and found that consent had been recorded in the patient notes.
  • GPs were not always familiar with the Deprivation of Liberty Safeguards (DoLS). At this inspection, we reviewed staff training records. Staff had received update training on the Mental Capacity Act and Deprivation of Liberty Safeguards within the last 12 months. Staff we spoke with understood their roles and responsibilities under this legislation.

However, there were areas where the practice should make improvements:

  • The practice should ensure that all staff can access practice policy and procedures relating to the storage and management of liquid nitrogen (a hazardous substance).
  • The practice should ensure that treatment rooms are kept uncluttered to avoid impeding fire exits; to reduce the risk of accidents and as part of effective infection prevention and control.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 29 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bacon Lane Surgery on 29 September 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. However, the recording of significant event analysis (SEA) required improvement as we noted changes to practice as a result of SEAs were not documented in all cases .
  • Risks to patients were assessed however they were not in all cases well managed. For example, those relating to general health and safety.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had a triage-led appointment system and some patients commented that they did not find it easy to get an appointment particularly with their preferred GP.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs however the practice was in need of an upgrade. The provider had applied for funding from the CCG to improve the premises and they were awaiting the decision.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure the recommendations from the fire risk assessment, health and safety audit, legionella risk assessment and the boiler inspection are implemented to mitigate risk to patients and staff.

In addition the provider should:

  • Improve the documentation of significant event analysis (SEA) in particular changes to practice as a result of SEAs.
  • Ensure fire drills are rehearsed and documented and fire alarms are checked regularly.
  • Develop a health and safety policy specific to the practice.
  • Ensure consent is documented in patient notes when carrying out joint injections.
  • Ensure all the GPs are familiar with the Deprivation of Liberty Safeguards (DoLS).
  • Continue to improve patient satisfaction with access to appointments, getting through to the practice by phone, access to a preferred GP and with the handling of repeat prescription requests.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 29 May 2014

During an inspection looking at part of the service

On our inspection of 22 January 2014 we found that the provider had not made arrangements for all staff to attend training in Basic Life Support (BSL) and there was no evidence that all staff had undertaken training in safeguarding children and adults. We also found that there was no evidence of a cleaning schedule and infection control audit. The appropriate recruitment checks had not taken place prior to some staff commencing their employment.

The provider wrote to us on 14 March 2014 to inform us they would arrange training for staff in BLS and safeguarding children and adults. They informed us they would ensure the required staff recruitment documentation was sought and records in relation to cleaning and infection control would be improved.

During this inspection we reviewed the progress the provider had made to meet requirements relating to the care and welfare of people who used the service, safeguarding people who used services from abuse, cleanliness and infection control and requirements relating to workers. We found that the provider had made arrangements to ensure that staff had received training in BSL and safeguarding children and adults. We saw that a formal system was in place for planning and recording cleaning tasks. The provider had carried out the relevant recruitment checks for staff who worked at the surgery.

Inspection carried out on 22 January 2014

During a routine inspection

During our inspection, we spoke with seven people who used the service and four members of the Patient Participation Group (PPG). We also spoke with six members of staff which included two GPs, the practice manager and three receptionist/administrative staff.

One person we spoke with told us "the doctors are very good� and people were positive about the clinical care provided by the practice. However, people told us that they were not satisfied with the triage appointment system, experienced difficulties getting an appointment and were not happy with the waiting times at the surgery. One person told us that the triage and appointment system was �dreadful�. Another person said �waiting times are getting worse�.

We found that patients were informed and involved in the care provided to them.

We observed that the provider had a safeguarding adults� policy and a separate policy for safeguarding children. We noted that staff who had started employment at the practice after 2011 had not yet received safeguarding training. However, we noted that all staff had been booked to attend a safeguarding training course.

We found that the practice was not following government guidelines in relation to the safe management of clinical waste.

We observed that there was a lack of evidence available to confirm that appropriate recruitment checks had been carried out for all staff.

We saw evidence that the provider had a system in place to monitor quality and safety.