Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beaconsfield Road Surgery on 20 April 2017. Overall the practice is rated as Good

The practice had previously been inspected on 08 December 2015 when it was rated as Requires Improvement overall, Requires Improvement in the Safe, Effective and Well-led domains and Good in the Caring and Responsive domains. The practice was found to be in breach of the regulations and a further inspection was carried out on 26 July 2016 to assess whether the practice had taken action to resolve the breaches in regulations. It was found that insufficient improvements had been made and the ratings remained the same. Warning notices were issued against the practice in respect of Safe Care and Treatment, Staffing and the recruitment of Fit and Proper Persons. The areas where the provider was advised that they must make improvements were:

To ensure that risk assessments relating to the need for a criminal records check via the Disclosure and Barring Services were undertaken prior to each new staff member commencing in post. Also to ensure that the risk assessment process identified and mitigated all of the potential risks associated with this.

To ensure that recruitment checks were consistently undertaken prior to a staff member commencing in employment and that records of this were maintained.

To ensure that fire safety rehearsals were carried out in line with an associated risk assessment.

To ensure all clinical staff had an up to date record of safeguarding children and vulnerable adults training and training in the Mental Capacity Act 2005.

To ensure that training records were maintained and accessible in relation to all areas of training need for all staff within the practice.

To ensure that all risk assessments including legionella were accessible and that a system for adopting policies and procedures within the practice was clear.

On this occasion 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.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. For example fire safety rehearsals had been carried out.
• Staff were aware of current evidence based guidance. Training records had been updated and were maintained to show all training requirements for staff.
• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. Including training for the safeguarding of children and vulnerable adults and training in the Mental Capacity Act 2005.
• New staff had received the required recruitment checks including a risk assessment relating to the need for a criminal record check.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day and open surgeries available two mornings a week.
• 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 management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

Monitor adherence to the new internal security protocol and internal prescription tracking to ensure that the systems become embedded.

To increase the number of patients with mental health conditions who have a comprehensive care plan, and record of blood pressure and alcohol consumption recorded in their clinical records.

To monitor the uptake of childhood immunisations in response to the introduction of new recall systems and clinic structure.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Beaconsfield Road Surgery on 8 December 2015. Breaches of legal requirements were found during that inspection within the safe, effective and well-led domains. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements in relation to the following:

• Ensure that policies and procedures are implemented to keep blank prescriptions secure at all times.
• Ensure all actions identified by infection control auditing processes are implemented including improvements to the building.
• Ensure that all policies, procedures and risk assessments in place for assessing and monitoring risks to staff, patients and visitors, including fire safety arrangements and the legionella risk assessment are signed, dated and reviewed on a regular basis and that any actions identified are implemented. In particular ensuring that regular rehearsals of fire safety and evacuation procedures are carried out and fire escape routes are assessed.
• Ensure staff undertake training to enable them to gain the knowledge required in order to fulfil the duties and responsibilities pertaining to their role, including training in the safeguarding of children and vulnerable adults and the Mental Capacity Act 2005.

We undertook a focused inspection on 26 July 2016 to check that the provider had implemented their action plan and to confirm that they now met legal requirements. 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 on our website at www.cqc.org.uk

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

• Risk assessments were not always being undertaken to identify when staff required a criminal records check via the Disclosure and Barring Service.

• Recruitment checks were not always undertaken prior to a staff member commencing in employment.

• Fire safety rehearsals continued not to be carried out.

• Not all clinical staff had an up to date records of safeguarding children and vulnerable adults training or training in the Mental Capacity Act 2005.

• Training records were unavailable in relation to areas such as health and safety and fire safety.

• Risk assessments such as legionella were not accessible on the day of inspection and the system for adopting relevant policies was unclear.

• Security and tracking of blank prescription pads was in place.

• Action relating to an infection control audit had been taken and further actions monitored by the practice.

The areas where the provider must make improvements are:

• Ensure that risk assessments relating to the need for a criminal records check via the Disclosure and Barring Services are undertaken prior to each new staff member commencing in post. Ensure that the risk assessment process identifies and mitigates all of the potential risks associated with this.

• Ensure that recruitment checks are consistently undertaken prior to a staff member commencing in employment and that records of this are maintained.

• Ensure that fire safety rehearsals are carried out in line with an associated risk assessment.

• Ensure all clinical staff have an up to date record of safeguarding children and vulnerable adults training and training in the Mental Capacity Act 2005.

• Ensure that training records are maintained and accessible in relation to all areas of training need for all staff within the practice.

• Ensure that all risk assessments including legionella are accessible and that a system for adopting policies and procedures within the practice is clear.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beaconsfield Road Surgery on 20 April 2017. Overall the practice is rated as Good

The practice had previously been inspected on 08 December 2015 when it was rated as Requires Improvement overall, Requires Improvement in the Safe, Effective and Well-led domains and Good in the Caring and Responsive domains. The practice was found to be in breach of the regulations and a further inspection was carried out on 26 July 2016 to assess whether the practice had taken action to resolve the breaches in regulations. It was found that insufficient improvements had been made and the ratings remained the same. Warning notices were issued against the practice in respect of Safe Care and Treatment, Staffing and the recruitment of Fit and Proper Persons. The areas where the provider was advised that they must make improvements were:

To ensure that risk assessments relating to the need for a criminal records check via the Disclosure and Barring Services were undertaken prior to each new staff member commencing in post. Also to ensure that the risk assessment process identified and mitigated all of the potential risks associated with this.

To ensure that recruitment checks were consistently undertaken prior to a staff member commencing in employment and that records of this were maintained.

To ensure that fire safety rehearsals were carried out in line with an associated risk assessment.

To ensure all clinical staff had an up to date record of safeguarding children and vulnerable adults training and training in the Mental Capacity Act 2005.

To ensure that training records were maintained and accessible in relation to all areas of training need for all staff within the practice.

To ensure that all risk assessments including legionella were accessible and that a system for adopting policies and procedures within the practice was clear.

On this occasion 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.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. For example fire safety rehearsals had been carried out.
• Staff were aware of current evidence based guidance. Training records had been updated and were maintained to show all training requirements for staff.
• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. Including training for the safeguarding of children and vulnerable adults and training in the Mental Capacity Act 2005.
• New staff had received the required recruitment checks including a risk assessment relating to the need for a criminal record check.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day and open surgeries available two mornings a week.
• 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 management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

Monitor adherence to the new internal security protocol and internal prescription tracking to ensure that the systems become embedded.

To increase the number of patients with mental health conditions who have a comprehensive care plan, and record of blood pressure and alcohol consumption recorded in their clinical records.

To monitor the uptake of childhood immunisations in response to the introduction of new recall systems and clinic structure.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice