Updated 31 August 2016
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of this practice on 2 December 2015. Breaches of legal requirement were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet this legal requirement in relation to the regulatory breach of the Health and Social Care Act 2008 (Regulated Activities) 2014, Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed.
We undertook this focused inspection on 10 August 2016 to check that they had followed their plan and to confirm they now met the legal requirement. 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 Avenue Medical Practice on our website www.cqc.org.uk.
Overall the practice is rated Good. Specifically, following the focused inspection we found the practice to be good for providing safe and well-led services.
Our key findings across all the areas we inspected were as follows:
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All staff who performed chaperone duties had received training for the role and a Disclosure and Barring Service (DBS) check had been completed (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
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Systems and processes were in place to keep people safe. For example, the system to check and monitor the temperature of the medical fridges had been reviewed. The healthcare assistants had attended a vaccination and immunisation training programme. We saw evidence that patient specific directions were attributable to a prescriber and demonstrated individual patient consideration to allow healthcare assistants to administer vaccinations. We reviewed a random sample of medical consumables within the practice and all were found to be within their expiry date. The practice had implemented a system to monitor and control this.
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The partners had reviewed the governance framework to support performance and deliver good quality patient care. We saw evidence staff had received an up to date job description. All had received an appraisal within the last 12 months with the exception of the nurse practitioner who had a date for this scheduled. We saw evidence a computerised training matrix had been implemented to monitor staff training needs.
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We saw evidence that risk assessments had been completed. A building health and safety risk assessment and a legionella risk assessment had been completed (legionella is a term for a particular bacterium which can contaminate water systems in buildings).
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice