Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Petworth Surgery on 7 June 2016. The overall rating for the practice was good. However, during this inspection we found a breach of legal requirements and the provider was rated as requires improvement under the safe domain. The full comprehensive report for the June 2016 inspection can be found by selecting the ‘all reports’ link for Petworth Surgery on our website at www.cqc.org.uk.
Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-
- Ensuring that all significant events were fully recorded centrally at the practice and a comprehensive audit trail was maintained.
- Improving policies and procedures to ensure that blank prescription forms were monitored and tracked and improving security arrangements for access to controlled drugs.
- Ensuring robust arrangements were in place for the management of infection control and for the assessment, monitoring and minimising of associated risks. This included staff receiving training on infection control and cleaning was recorded according to a defined schedule.
- Ensuring that recruitment checks were completed, including proof of identification and references.
- Ensuring non-clinical staff were either risk assessed or had received a Disclosure and Barring Scheme (DBS) check (especially for those who acted as chaperones).
This inspection was an announced focused inspection carried out on 25 January 2017 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 7 June 2016. The focused inspection has determined that the provider was now meeting all requirements and is now rated as good under the safe domain This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Our key findings were as follows:
- Significant events were fully recorded centrally and discussed at regular meetings with actions recorded and dated. There was a comprehensive audit trail and electronic copies were available as well as paper copies which were stored centrally so they could be referred to if necessary.
- The practice was monitoring and tracking blank prescription forms including when prescriptions were delivered to the practice and when disseminated to the individual doctor’s rooms. The practice was reconfiguring the layout of the dispensary and reception area. We saw this would allow for greater security and improve confidentially. Controlled drugs were stored in a locked cabinet within a second locked cabinet. Keys to both these cabinets were stored within a key safe which could only be accessed by authorised staff.
- The practice had a new infection control lead who was the practice nurse. We saw evidence of training and the attendance of various forums for infection control. Infection control audits were undertaken every six months and there had been a recent Infection control audit in January 2017. We saw that actions had been recorded to address any concerns found. The practice had also employed a new cleaning company and we saw daily cleaning plans which were dated and signed. There was a dedicated cleaning folder where we saw evidence of daily, weekly and monthly cleaning schedules for various elements of the practice. All staff had received training on infection control which included hand washing.
- We reviewed the latest recruitment file for a new employee at the practice and found that it contained all the required information. For example, a full works history, Disclosure and Barring Scheme (DBS) check, proof of identification and references.
- We saw minutes to a meeting where the practice had discussed which roles were required to have a Disclosure and Barring Scheme (DBS) check. We saw evidence that all those staff members who were also acting as chaperones had received a DBS check and that a new risk assessment was in place for those who were not required to have one.
In addition we saw evidence of:
- The new practice manager, who had been in post since November 2016, was reviewing all policies and procedures and ensuring they were up to date and relevant. Policies which had been reviewed contained the last review date.
- The practice was in the process of completing building work to change the layout of the dispensary. This would ensure restricted access with the dispensary only being accessed by authorised staff.
- The practice manager had a training matrix which recorded staff members and their completed training. The practice manager was also able to access training logs and certificates of training from the e-learning training tools that were used.
- Complaints were a standing item on the weekly meetings and the bi-monthly strategy meetings and information was recorded with dates and actions taken. We saw these were recorded electronically as well as paper copies being stored centrally so they could be referred to if necessary.
- The practice had a variety of meetings for staff. This included weekly meetings, nurse meetings and bi-monthly development meetings. There was also a bi-monthly strategy meeting with the partners and regular meetings with the administration staff. The practice manager informed us that there were plans in place for a weekly huddle meeting with key staff members to ensure important information was disseminated. This ensured that all staff were kept up to date with changes with the practice and had a forum to raise questions or concerns.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice