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Reports


Review carried out on 22 October 2019

During an annual regulatory review

We reviewed the information available to us about Petworth Surgery on 22 October 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 25 January 2017

During an inspection looking at part of the service

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

Inspection carried out on 7 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Petworth Surgery on 7 June 2016. Overall the practice is rated as good.

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

  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was an open and transparent approach to safety and an effective system in place for reporting significant events, although we found the recording processes could be improved.
  • Most risks to patients were assessed and well managed. However, some systems and processes to address risks were not implemented well enough to ensure patients and staff were kept safe. This included the arrangements to manage infection control, the safe storage and security of controlled drugs, completion of recruitment checks, and the monitoring and tracking of prescriptions.
  • 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.
  • All patients had a named GP. The practice management and all staff considered patient care to be their top priority and demonstrated a focus on knowing their patients individually, in order to provide continuity of care.
  • Patients said they found it easy to make an appointment, with urgent appointments available the same day. The patients we spoke with on the day of the inspection told us they were happy with the care and treatment they received.
  • 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. 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 patient participation group was relatively new, but had made a number of improvements to the practice and ensured regular communication with the patients.

The areas where the provider must make improvements are:

  • Ensure that all significant events are fully recorded centrally at the practice to ensure a comprehensive audit trail is maintained.
  • Improve policies and procedures to ensure the monitoring and tracking of blank prescriptions at all times.
  • Ensure that access to controlled drugs is restricted and improve the security arrangements for their storage.
  • Ensure there are robust arrangements in place for the management of infection control and for the assessment, monitoring and minimising of associated risks. This includes that all staff receive training that is appropriate to their job role on infection control and that all cleaning is recorded according to a defined schedule.
  • Ensure that recruitment checks are completed, including proof of identification and references. Ensure that all non-clinical staff are either risk assessed or have received a Disclosure and Barring Scheme (DBS) check especially those who act as chaperones.

In addition the provider should:

  • Ensure all practice policies and procedures are dated at the time of writing and last review.
  • Review the practice layout in order to consider methods to restrict access to the dispensary to the dispensary staff only.
  • Continue to improve records of training to ensure all staff have completed their training requirements.
  • Consider improvements to the recording of complaints to enhance efficiency and the management of the process.
  • Ensure there are arrangements to provide regular communication and updates to all staff regarding senior management changes in light of succession planning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice