Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 22 September 2016. We set a requirement in relation to safe care and treatment. The practice sent in an action plan informing us about what they would do to meet legal requirements in relation to the following;

• The systems and processes to address risk were not robust enough to ensure patients were kept safe. The practice did not risk assess the need to make appropriate emergency medicines immediately available in the practice.

During the initial inspection we also found areas where improvements should be made:

• The practice should be proactive in identifying carers.
• Ensure that the practice is following the guidance around infection control monitoring set out in the Code of Practice by the Department of Health.
• Ensure the practice holds a copy of the legionella risk assessment.
• Ensure all medical equipment is regularly calibrated.
• Ensure regular fire drills are undertaken.

The practice told us these issues were addressed by 26 September 2016 and have provided us with evidence to show they had taken the action to address the concerns.

We undertook a desk top review on 19 December 2016 to make a judgement about whether their actions had addressed the requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for on our website at www.cqc.org.uk

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 Cathedral Medical Centre on 22 September 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 the practice had systems 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 robust enough to ensure patients were kept safe. For example, infection control audits, equipment calibration and fire drills.
• The practice had identified 91 patients as carers (0.9% of the practice list).
• Patient safety alerts were logged, shared and initial searches were completed and the changes effected.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
• 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• The practice offered minor surgery on site. This included coil and contraception implants however the practice had not risk assessed the need to make emergency medicines immediately available for the treatment of a specific complication for that procedure in the practice.

The areas where the provider should make improvements are:

• The practice should be proactive in identifying carers.
• Ensure that the practice is following the guidance around infection control monitoring as set out in the Code of Practice set out by the Department of Health.
• Ensure the practice holds a copy of the legionella risk assessment.
• Ensure all medical equipment is regularly calibrated.
• Ensure regular fire drills are undertaken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice