Updated 23 December 2016
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of this practice on 16 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014; Regulation 12 Safe Care and Treatment; Regulation 16 Receiving and Acting on Complaints; Regulation 17 Good Governance and Regulation 19 Fit and Proper Persons employed.
We carried out a focused inspection on 27 November 2016 to check that the practice had followed their action plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Carrfield Medical Practice on our website at www.cqc.org.uk.
Overall the practice is rated as good. Specifically,following the focused inspection we found the practice to be good for providing safe, effective, responsive and well-led services.
Our key findings across all the areas we inspected were as follows:
- Systems and processes were in place to keep people safe. For example, a Legionella risk assessment had been carried out in June 2016, and a new refridgerator for the storage of vaccinations had been purchased and was not over stocked with products.
- Disclosure and barring service (DBS) checks had been completed for all staff.
- An action arising from the annual infection prevention and control audit had been carried out i.e. new chairs were seen in the waiting room.
- There was a system in place for reporting and recording significant events. We saw evidence that these significant events had been reviewed, discussed at practice meetings and learning had taken place as a result.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. We saw evidence that a system was in place to ensure that clinicians were kept up to date with national guidance and MHRA alerts.
- We saw evidence that the management of prescriptions complied with NHS Protect Guidance.
- The practice had established a programme of internal audit to monitor quality and to make improvements.
- We saw that improvements were made to the quality of care as a result of complaints and we saw a complaints process and register of actions.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice