Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ashwell Surgery on 17 February 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 in place for reporting and recording significant events.
• Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• There was a clear leadership structure and staff felt supported by 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.

We saw one area of outstanding practice:

The practice provided a community anticoagulation service. This is a local service for the monitoring of patients on blood thinning medication, for those patients that can attend the practice and for the housebound. The practice offered this service to patients registered with 10 out of the 12 practices in the Local CCG area, which enabled the patient to receive a local service without the need to attend a hospital clinic. This service was provided by a lead GP supported by dedicated qualified anticoagulation nurses.

The areas where the provider must make improvement are:

• Ensure staff that act as chaperones are risk assessed for the need of a Disclosure and Barring Check (DBS) and those that require one receive a DBS check.

• Ensure that the healthcare assistant has patient specific instructions from a prescriber before administering medicines.

• Ensure an appropriate system is implemented for the safe management of controlled drugs.

The areas where the provider should make improvement are:

• Introduce a system to risk assess the need for a DBS check at recruitment and for long standing staff.

• Complete the delivery of the appraisals for non clinical staff and competency assessments for dispensary staff in line with the programme schedule; completion date 31 March 2016.

• Carry out periodic fire drills.

• Complete the revision of the business continuity plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This inspection was a follow up inspection to one we completed in January 2014. During the inspection in January 2014 we identified concerns that written consent was not always obtained prior to minor surgery. As a result, during this inspection, we looked at the paperwork that had been introduced and did not need to speak with people who used the service.

We found that the provider had introduced consent procedures for minor surgery. We saw evidence that consent forms had been produced that explained relevant information about each different procedure. We saw evidence that consent forms had been completed by the doctor and the patient.

Letter from the Chief Inspector of General Practice

We carried out a desk-based focused review of Ashwell Surgery on 14 March 2017. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 17 February 2016. During our inspection in February 2016 we identified regulatory breaches in relation to:

• Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment
• Regulation 17 HSCA (RA) Regulations 2014 good governance

This report only covers our findings in relation to the areas identified as requiring improvement following our inspection in February 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for Ashwell Surgery on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in February 2016 were as follows:

• Ensure staff that act as chaperones are risk assessed for the need of a Disclosure and Barring Check (DBS) and those that require one receive a DBS check.
• Ensure that the healthcare assistant has patient specific instructions from a prescriber before administering medicines.
• Ensure an appropriate system is implemented for the safe management of controlled drugs.

In addition, the practice were told they should:

• Introduce a system to risk assess the need for a DBS check at recruitment and for long standing staff.
• Complete the delivery of the appraisals for non- clinical staff and competency assessments for dispensary staff in line with the programme schedule; completion date 31 March 2016.
• Carry out periodic fire drills.
• Complete the revision of the business continuity plan.

Our focused review on 14 March 2017 showed that improvements had been made and our key findings across the areas we inspected were as follows:

• Systems had been improved to ensure that all non-clinical staff roles had been risk assessed to determine if a Disclosure and Barring (DBS) check was required.
• The practice had an appropriate system in place to ensure patient specific directions were approved by a prescriber prior to the health care assistant administering vaccines.
• Systems had been improved to ensure patient identification was checked prior to the issuing of any controlled drugs.
• The practice had an appraisal policy and procedure in place and all non-clinical staff members had received an appraisal within the last 12 months.
• Fire drills were carried out on a regular basis and the practice maintained a record of this.
• The practice had a business continuity plan in place in place for major incidents such as power failure or building damage.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice