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Inspection Summary


Overall summary & rating

Good

Updated 8 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at the St Agnes Surgery on 30 August 2016. This was to review the actions taken by the provider as a result of our issuing two legal requirements. In October 2015 the practice did not have safe systems in place for the safe management of medicines and appropriate risk assessments were not in place to ensure staff within the practice had received appropriate checks and up to date mandatory training.

Overall the practice has been rated as Good following our findings, with safe and well led now rated as good. This report should be read in conjunction with our report published on 4 February 2016 where the effective, responsive and caring domains were rated as Good. This can be done by selecting the 'all reports' link for St Agnes Surgery on our website at www.cqc.org.uk

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

  • New procedures following the national guidelines for storing and recording the use of blank prescriptions were in place to ensure national guidance is followed.

  • New arrangements for prescribing under Patient Group Directives had been put in place to ensure all were authorised for use in the practice.

  • We found all staff who acted as chaperones had been trained for the role and had received a disclosure and barring service check (DBS). (DBS 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 children or adults who may be vulnerable).

  • New processes had been put in place to ensure recruitment arrangements included all the necessary employment checks for all staff.

  • The provider had put in place processes and records to demonstrate risks to health, safety and welfare of people are well managed in relation to calibration of equipment and the testing of electrical equipment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 8 November 2016

At our inspection in October 2015 we found that the provider needed to make improvements in;

  • Storing and recording blank prescriptions

  • Reviewing arrangements for prescribing under patient group directions

  • Carrying out recommended employment checks for all staff.

  • Ensuring risk assessments were in place for all staff in roles deemed not to need a Disclosure and Barring Service check particularly for staff undertaking chaperone duties.

The practice is rated as good for providing safe services.

At this inspection, we found:-

  • New procedures following the national guidelines for storing and recording the use of blank prescriptions were in place to ensure national guidance is followed.

  • New arrangements for prescribing under Patient Group Directives had been put in place to ensure all were authorised for use in the practice.

  • We found all staff who acted as chaperones had been trained for the role and had received a disclosure and barring service check (DBS). (DBS 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 children or adults who may be vulnerable).

  • New processes had been put in place to ensure recruitment arrangements included all the necessary employment checks for all staff.

  • The provider had put in place processes and records to demonstrate risks to health, safety and welfare of people are well managed in relation to infection control and the calibration of equipment and the testing of electrical equipment.

At the last inspection, we found:

  • There was an effective system in place for reporting and recording significant events.

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When there were unintended or unexpected safety incidents, patients received reasonable support, truthful information, a verbal and written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

Effective

Good

Updated 8 November 2016

Not inspected as previously rated as good.

Caring

Good

Updated 8 November 2016

Not inspected as previously rated as good.

Responsive

Good

Updated 8 November 2016

Not inspected as previously rated as good.

Well-led

Good

Updated 8 November 2016

At our inspection in October 2015 we found that the provider needed to make improvements in;

  • Having systems and processes in place, that demonstrate risks to health, safety and welfare of people were well managed in relation to the governance of risks to staff and patients.

The practice is rated as good for providing well led services.

At this inspection we found:

The provider had put in place effective systems to monitor safety risks in regards to fire safety, infection control, and recruitment policies.

New systems had been put in place to centralise all staff training undertaken to assist with the management and monitoring of staff development.

All complaints, both verbal and written were recorded to allow for the identification of themes and trends.

At the last inspection, we found:

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

People with long term conditions

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good

Families, children and young people

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good

Older people

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good

Working age people (including those recently retired and students)

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good

People experiencing poor mental health (including people with dementia)

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good

People whose circumstances may make them vulnerable

Good

Updated 8 November 2016

We did not inspect the population groups as part of this inspection. However, the outcomes we found when inspecting the Safe and Well led domains means the ratings category for this population group is now Good