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Inspection carried out on 17 May 2017

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 at Lambourn Surgery on 7 October 2016. The overall rating for the practice was good. However, the practice was found to require improvement in the provision of safe services. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Lambourn Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 7 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Provision of safe services is now rated good and overall the practice remains rated as good.

Our key findings were as follows:

  • Medicines fridges were kept in a secure location within the practice.
  • Vaccines stored within medicines refrigerators were kept in accordance with best practice guidance.
  • Treatment room flooring was fitted in line with best practice for reducing the risk of cross infection.
  • Appropriate systems were in place for the safe disposal of sharps bins.
  • Staff training was up to date and relevant to the roles of staff.
  • Competency checks had been completed and recorded for dispensary staff.
  • An appropriate system was in place to report dispensing incidents, including near misses. Learning from dispensary incidents was shared and staff were aware of the learning.

We found aspects of the service where the provider should make improvement:

  • A review of the risk assessment for keeping liquid nitrogen on site should be completed in sufficient detail to identify all storage risks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 7 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lambourn Surgery on 7 October 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 well managed.
  • The practice had policies and systems in place for infection control purposes.  
  • Systems were not firmly embedded to regularly monitor the quality of the dispensing process. Some evidence of auditing was demonstrated, although there was poor staff awareness, near misses were not captured and controlled drug audits were not comprehensive. 
  • The storage conditions and security of vaccines were not always in line with relevant guidance. Steps were taken to improve security of vaccines on the day of the inspection.

  • 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. However, not all staff had received training updates in a timely fashion.
  • 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 promptly to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities 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 proactively sought feedback from staff and patients, which it acted on.
  • Staff had access to appropriate policies and protocols.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had systems in place to promote the benefits of cancer screening programmes.

We saw one area of outstanding practice:

  • The practice had taken steps to assess patients’ needs and increase accessibility to the practice. They had completed a dementia audit tool and taken steps to make the environment more suitable for people with dementia, including ensuring that toilet doors were a contrasting colour to the rest of the environment. The practice had signed up to the Dementia Friends scheme and staff had received training on how to support patients with dementia. The practice also offered patients with visual difficulties the facility to request repeat prescriptions over the telephone.

The areas where the provider must make improvement are:

  • Ensure systems are embedded to regularly monitor the quality of the dispensing process.
  • Review the storage conditions and security of vaccines to ensure it is in line with relevant guidance.

The areas where the provider should make improvement are:

  • Ensure that all clinical staff are aware of how to determine when sharps bins are full and need to be replaced.
  • Training should be undertaken within the timescales outlined by the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 3 December 2013

During a routine inspection

Patients were treated respectfully and their privacy was protected. Patients we spoke with told us that they were always spoken to in a professional way. One patient said “I like the fact that the GP comes to collect you from the waiting room in person”.

The care and welfare of patients was important to all staff at the practice. Some patients told us that staff often went over and above their normal duties to support patients.

The practice had appropriate processes and policies in place to support vulnerable children and adults. Patients we spoke with told us they felt safe when visiting the practice.

Patients were treated in a clean and hygienic environment. We found the practice to be clean and free from odours.

We found that patients were asked for their feedback through regular surveys. Patients we spoke with explained that they had been asked for comments about their patient experience in the past.