Archived: Heeley Green Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Heeley Green Surgery on 2 November 2016. Overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and recording significant events.
• Some risks to patients were assessed although there were shortfalls identified with regards to no COSHH risk assessment of products, no record of fire drills, lack of cleaning schedules and no system to monitor or track blank prescriptions within the practice.
• 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, although there was limited overview of what training staff had received or when it was due.
• 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.
• Patients said they found it easy to make an appointment with a named 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 leadership structure and staff told us they 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:

• Implement a system to monitor and track blank prescriptions within the practice as recommended in NHS Protect Security of Prescription Guidance.

• Review fire safety systems to ensure fire escape routes are unlocked when the premises are in use as outlined in the practice’s fire risk assessment and undertake regular fire drills to ensure the manual fire alarm system works effectively.

• Review the control of substances hazardous to health (COSHH) regulations 2002 and complete a COSHH risk assessment of products in the practice.

• Ensure cleaning schedules are in place for all equipment used for direct patient care and records of cleaning are kept.

• Implement a system to document all training staff received and monitor when training updates are due.

• Ensure staff leave their workstations secure and remove their smartcards from the computers  as outlined in the application for NHS Care Record declaration.

The areas where the provider should make improvement are:

• Maintain a complete record of the immunity status of clinical staff as specified in the national Green Book (immunisations against infectious disease) guidance for healthcare staff.

• Monitor the recording of the use of chaperones in patient records in line with the practice policy. 

• Document cleaning schedules to monitor what cleaning of the premises has taken place and when.

• Ensure staff have access to the business continuity plan to provide guidance on contingency plans and assistance in an emergency.

• Complete a risk assessment to review the frequency of training of basic life support for non clinical staff as recommended in the Resuscitation Council (UK) Guidelines for staff working in a primary care organisation.

• Ensure all clinical waste sharps containers are appropriately labelled as outlined in the Health Technical Memorandum 07-01 – Safe management of healthcare waste guidelines.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice