Archived: Caerleon Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Caerleon Surgery on Thursday 18 February 2016. Overall the practice is rated as requires improvement.

• There was an open and transparent approach to safety and a system was in place for reporting significant events. However, the recording of significant events were insufficiently detailed to show lessons learned, action to be taken and ongoing monitoring.
• Clinical staff had the skills, knowledge and experience to deliver effective care and treatment. However administration and reception staff had not received training related to keeping patients safe, this included chaperoning, health and safety and infection control.
• Risks to patients were assessed, however a full legionella risk assessment had not been completed.
• Robust systems were not in place to ensure that appropriate pre-employment checks were carried out for all staff.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice proactively sought feedback from staff and patients, which it acted on.
• There was a clear leadership structure and staff felt supported by the management team. The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Ensure that staff who undertake the role of a chaperone have a Disclosure and Barring Service (DBS) check or an appropriate risk assessment carried out to demonstrate why a DBS check is not in place.
• Ensure that all staff receive appropriate support, training, development and appraisals to enable them to carry out the duties they are employed to do.
• Ensure that all necessary employment checks are made for all staff. This should include a full employment history, DBS check and health history.
• Implement robust governance arrangements to ensure appropriate systems are in place for assessing and monitoring the quality of services provided. This should include completed clinical audit cycles and the maintenance of accurate records to demonstrate ongoing improvements.

The areas where the provider should make improvement are:

• Ensure that a full risk assessment for legionella is carried out.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice