Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 29 June 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 and 19 of

HSCA (Regulated Activities) Regulations 2014

.

We undertook a focussed inspection on 16 September 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements.

You can read the last comprehensive inspection report from June 2016 by following the link http://www.cqc.org.uk/location/1-548150327 or selecting the ‘all reports’ link for Countesthorpe Health Centre on our website at

www.cqc.co.uk

At this inspection we found that:

• There was now an effective system in place to ensure that relevant training was undertaken and kept up to date.

  The system for checking and acting on abnormal pathology results had been reviewed and the protocol updated to ensure the system was effective.

• Outstanding actions identified in risk assessments and audits had been addressed.

• The system for the identification of carers had been improved.

• The protocol for maintaining the cold chain in respect of vaccination fridges was not being followed but action was taken to rectify this.

The areas where the provider should make improvements are:

• Further embed the process which has been introduced to consistently monitor

  fridge temperatures in order to adequately maintain the cold chain in respect of vaccines.

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 Countesthorpe Health Centre on 29 June 2016. Overall the practice is rated as requires improvement.

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

• Although the practice was proactive in providing requested training, there was not a robust system in place to ensure that mandatory training was undertaken and kept up to date.

• The practice did not have a robust system for checking and acting on abnormal pathology results.

• Risks to patients were assessed but the identified risks had not all been acted upon.
• There was an effective system in place for reporting and recording significant events.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Feedback from patients about their care was consistently positive.

• 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 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 improvements are:

• Ensure there is a robust system in place to ensure that relevant training is undertaken and kept up to date.

• Have a robust system for checking and acting on abnormal pathology results.

• Ensure all required outstanding actions from risk assessments and infection control audit are implemented.

The areas where the provider should make improvement are:

• To improve the system for the identification of carers.

• Ensure secondary thermometers are being used in vaccine refrigerators.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This inspection was carried out to see if improvements had been made following our inspection of 11 November 2013.

During this inspection, we spoke with the assistant practice manager. We did not speak with patients using the service.

The provider had systems in place to protect patients, staff and visitors against the risks of unsafe or unsuitable premises. We found that an independent specialist company had carried out a Legionella risk assessment and water sampling. We found signs were displayed next to sinks warning of the risk of the hot water temperature. This meant that the provider had considered the risks relating to Legionella and the hot water temperatures.

We spoke with five patients about their experiences and most of the patients identified positive experiences. One person said that “The attitude (of reception staff) on the phone was lovely.” The appointment system caused some patients concern, one patient said “I would like to be able to get an appointment more easily, and then them (the GP’s) keep to time, sometimes they run 30 minutes late” and added “The on-line booking is helpful for me.”

Patients were generally positive about their experiences and told us reception staff were polite and helpful. One person stated (the doctor) “Spoke to me like I was an idiot.” We ascertained the person was unhappy with his current treatment, and though as yet had not made a complaint, was in the process of doing so. We made the Registered Manager aware of the patients concerns and frustration.

Medicines and vaccines are stored and dispensed appropriately.

The provider had systems in place for monitoring the quality of service provision, the PPG are active and have developed a number of questionnaires which are distributed to patients on an annual basis.

We found one area for improvement was a risk assessments was required to reduce the potential of cross infection at the practice.