8 March 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
This is a focused desk top review of evidence supplied by Hopwood Medical Practice for areas within the key question safe that required improvement following our full comprehensive inspection under the Health and Social Care Act 2008. At that inspection on 26 February 2016, the practice was rated good overall. However, within the key question safe, there were areas identified as requiring improvement, as the practice was not meeting the legislation at that time. The areas where the provider was told they must make improvements were as follows :
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Regulation 17 HSCA (RA) Regulations 2014 Good governance The registered person did not do all that was reasonably practicable to mitigate risks relating to the health, safety and welfare of service users and others who may be at risk. This was in breach of regulation 17 (1) (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Actions required following a fire risk assessment had not been completed. Significant events were not always recorded at the time they occurred and there was no analysis of significant events to ensure they were not repeated.
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Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed The registered person did not ensure all staff were of good character or were registered with the relevant professional body. This was in breach of regulation 19 (1) (a) (4) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A Disclosure and Barring Service (DBS) check had not been carried out on all clinicians prior to them starting work. The professional registration of clinicians was not routinely checked.
This is a focused desk top review of evidence supplied by Hopwood House Medical Practice for the areas of improvement identified within the key question safe. We received and assessed documentation to evidence that the practice had carried out their plan and now met the required level in relation to breaches in Regulation 17 and 19.
The overall rating for the practice remains as good. Our key findings were as follows:
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A Legionella Risk Assessment was completed on 16 March 2016
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Actions relating to fire safety were carried out. Health and safety checks were undertaken. The provider should ensure that all staff complete health and safety training at required intervals.
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The significant event policy was updated and significant events were dealt with appropriately and reviewed to ensure learning was achieved.
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The recruitment policy was updated to ensure that all appropriate documentation and checks of professional registration were obtained prior to employment.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice