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Archived: Drs Bilas & Thomas Good

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Reports


Inspection carried out on 15 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Drs Bilas & Thomas on 20 June 2016. After the comprehensive inspection, the practice was rated as requires improvement for providing safe services.

We issued a requirement notice in relation to:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Drs Bilas & Thomas on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 June 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 at our previous inspection on 20 June 2016. This report covers our findings in relation to those requirements.

Our key findings were as follows:

  • The recording of significant events had been reviewed and were sufficiently detailed to show that concerns identified about patients were appropriately followed up to prevent further occurrences and ensure improvements made were appropriate.
  • The practice had reviewed its systems and procedures to ensure the safe management of medicines.
  • Records were available to confirm that a full legionella risk assessment had been carried out.
  • The practice’s complaint handling procedures had been reviewed to ensure that the appropriate management of verbal complaints was included. Staff were made aware of the procedure to follow.
  • The practice chaperone practices had been reviewed to ensure that all staff were aware of the correct procedure to follow when carrying out the role.
  • Staff had received training to ensure that they were aware of the requirements of the Mental Capacity Act (MCA) 2005 and their responsibilities under the act as it relates to their role.

There was one area where the provider should make improvements:

  • Ensure that a risk assessment is completed to determine whether there is a need for a second thermometer to confirm the accuracy of the temperature of the fridge used to store medicines.

At this inspection we found that the practice had addressed all the concerns raised and is now rated as good for providing safe services.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 20 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Bilas & Thomas on 20 June 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Staff understood their responsibilities to raise concerns and to report incidents and near misses, however the practice did not have a formal system in place for the ongoing monitoring of significant events, incidents and accidents.
  • Arrangements were not in place to ensure that all risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The practice had a programme of continuous clinical and internal audit in order to monitor quality and make improvements.
  • The practice invested in staff development and training.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 by the management.
  • 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.

There were areas of practice where the provider must make improvements:

  • Ensure systems are put in place for the proper and safe management of medicines.
  • Ensure the practice undertakes a Legionella risk assessment.

There were areas of practice where the provider should make improvements:

  • Review the practice’s system for the ongoing monitoring of significant events with a view to preventing further occurrences and, ensuring that improvements made are appropriate.
  • Review complaint handling procedures and establish a system for identifying, receiving, recording, handling and responding to verbal complaints.
  • Review chaperone practices to ensure that all staff are aware of the correct procedure to follow when carrying out the role.
  • Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 17 June 2014

During an inspection looking at part of the service

We previously inspected Dr Bilas & Thomas on 13 January 2014. We found that improvements were required in relation to safeguarding children and vulnerable adults. We asked the provider to submit an action plan outlining how they intended to address the issues we had identified.

At this inspection visit we looked to see what improvements had been made. We met spoke with one of GP partners. We spoke with staff members including the deputy practice manager, a member of reception staff and the practice manager. We also spoke with one patient who agreed to speak to us so that we could get their view with regards to the service provided. We received positive comments from the patient in regards to the service and staff.

At our last inspection we found that improvements were required to ensure all staff followed up reported incidents to protect patients from the risk of abuse. At this inspection we found that steps were taken to ensure improvements were made in regards to safeguarding vulnerable people.

Inspection carried out on 13 January 2014

During a routine inspection

On the day of our inspection we spoke with six patients and six members of staff. One patient said, �They are really nice people, really friendly." All of the patients we spoke with said they were able to obtain appointments at a time to suit their needs. All the patients we spoke with said they felt the quality of care they received was good.

We saw that patient's views and experiences were taken into account in the way the service was provided which demonstrated that they felt listened to. All the patients we spoke with told us they were treated with dignity and respect. One patient told us, �They are very polite and helpful." We found that patients experienced care and treatment that met their needs.

Patients told us and we saw that care was delivered in a clean environment.

Staff had received training in safeguarding (protecting vulnerable adults and children). However, improvements were required to ensure all staff followed up reported incidents to protect patients from the risk of abuse.

There were established quality monitoring systems in place to assess and improve the quality of service that patients received.