- GP practice
Archived: Feldon Practice (Hawne Lane Branch)
All Inspections
16 March 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection visit of Hawne Lane Surgery, branch of Feldon Lane Practice in May 2016. As a result of our comprehensive inspection a breach of legal requirements were found and the practice was rated as requires improvements for providing well-led services. This was because we identified areas where the provider must make improvement and an area where the provider should improve.
We carried out a focussed desk based inspection of Hawne lane Surgery on 16 March 2017 to check that the provider had made improvements. 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 Feldon Lane (Hawne Lane Branch) on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:
- As part of our desk based inspection we noted improvements in the practices arrangements for risk management and record keeping. For example, during our previous inspection in May 2016 we identified gaps in the practices arrangements for formally assessing and managing risks associated with chaperoning and working alone.
- As part of our desk based inspection the practice provided evidence to confirm that all staff acting as chaperones had received a disclosure and barring (DBS) check; this included clinical and non-clinical staff. We also saw that risks associated with lone working had been formally assessed and was appropriately managed to support staff safety.
- We saw that record keeping had improved with regards to infection control and clear records were kept to demonstrate that medical equipment was regularly cleaned in line with infection control guidelines.
- During our inspection in May 2016 we found that the practice had not reviewed their results from the national GP patient survey. Most recently we found that the practice had since focussed on areas for improvement following publications of the national GP patient survey and a comparison of the surveys published in January and July 2016 highlighted some improvement to access.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
4 May 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Hawne Lane Surgery, branch surgery of Feldon Lane Practice on 4 May 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- The practice had defined and embedded systems in place to keep people safeguarded from abuse. There was a system in place for reporting and recording significant events and staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses.
- Staff assessed needs and delivered care in line with current evidence based guidance. Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment and results were circulated and discussed in the practice. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Governance and risk management arrangements were not always robust. We did not see evidence to demonstrate that risk was assessed and managed in the absence of disclosure and barring checks for members of the reception team who occasionally chaperoned.
- We observed the premises to be clean and tidy. However, we did not see evidence of records in place to reflect the cleaning of specific medical equipment, such as the equipment used for ear irrigation.
- Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that monthly multidisciplinary team meetings took place and a range of chronic disease and vulnerable patient registers were continually reviewed and discussed as part of these meetings.
- We noticed that members of staff were courteous and helpful to patients both attending at the reception desk and on the telephone.
- During our inspection staff spoke positively about the team and about working at the practice, however discussions with staff also highlighted that not all staff members were familiar with what the practices vision was.
The areas where the provider must make improvements are:
- Ensure records are kept to demonstrate that risk is assessed in the absence of disclosure and barring checks for members of the reception team who chaperone.
- Ensure records are kept to reflect the cleaning of medical equipment.
The areas where the provider should make improvement are:
- Address areas for improvement highlighted through patient feedback such as national survey results.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice