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Dr Cartwright & Mahfouz Good Also known as Keelinge House Surgery

Inspection Summary


Overall summary & rating

Good

Updated 21 January 2019

We carried out an announced comprehensive inspection at Drs Cartwright & Mahfouz on 20 November 2017. Overall the practice was rated as good with requires improvement for providing safe services. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Drs Cartwright & Mahfouz on our website at .

This inspection was a desk-based review carried out on 10 December 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 November 2017. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice remains rated as good.

Our key findings were as follows:

  • The practice had strengthened its recruitment procedures to include Disclosure and Barring Service (DBS) checks a physical and mental health assessment for all staff.
  • Environmental risks had been formally assessed and monitored.
  • The practice had redefined roles and responsibilities within the management structure.
  • An action plan had been produced to explore how ongoing improvement work could be used to address patient feedback

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 21 January 2019

At our previous inspection on 20 November 2017, we rated the practice as requires improvement for providing safe services. This was because the registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. In particular:

  • Appropriate checks had not always been carried out on staff employed.
  • Environmental risks had not always been formally assessed and monitored.
  • The prescription tracking system did not minimise the risk of fraud.
  • There was no formal induction programme for new staff.
  • There was no system in place to ensure regular reviews of policies and protocols and to assess that they governed activity.

These arrangements had improved sufficiently when we undertook a follow up inspection on 10 December 2018. The practice is now rated as good for providing safe services.

Safety systems and processes

  • At the last inspection in November 2017, we found shortfalls in the practice recruitment procedures. These included staff not having had a criminal record check through the Disclosure and Barring Service (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. Since the last inspection the provider had reviewed its policy for recruitment checks against the requirements detailed in schedule three of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. A risk assessment had been carried out on all staff to determine if a DBS check was required, and a new online system introduced for all staff who required a DBS check. A formal record of staff immunisation status was now maintained and a system for checking professional registration (where applicable) had been implemented. A health assessment had been completed on all staff.

Risks to patients

  • At the previous inspection in November 2017 we found that there was a detailed induction pack in place for medical students but not for staff members. Some non-clinical staff we spoke with told us they had shadowed experienced staff but had not completed a formal induction. Since the last inspection in November 2017, a formal induction checklist had been introduced which included an introduction to practice staff, organisation rules, health and safety and information governance.

Safe and appropriate use of medicines

  • At the November 2017 inspection, we found that the prescription tracking system was not effective because the clinical rooms were shared and prescription forms assigned to each room were used by different clinicians. This system had since been reviewed and improved and each clinician had prescription forms allocated to them individually. A lockable box had been provided to each prescriber to empty printers and store unused prescription forms that had been issued for additional security.

Track record on safety

The practice safety arrangements had been strengthened following recommendations made at the November 2017 inspection.

  • There were records to demonstrate that routine safety checks were now being undertaken, for example; for legionella monitoring.
  • The practice had carried out a fire risk assessment in September 2018.

Effective

Good

Updated 24 January 2018

Caring

Good

Updated 24 January 2018

Responsive

Good

Updated 24 January 2018

Well-led

Good

Updated 24 January 2018

Checks on specific services

People with long term conditions

Good

Updated 24 January 2018

Families, children and young people

Good

Updated 24 January 2018

Older people

Good

Updated 24 January 2018

Working age people (including those recently retired and students)

Good

Updated 24 January 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 24 January 2018

People whose circumstances may make them vulnerable

Good

Updated 24 January 2018