Letter from the Chief Inspector of General Practice

This is a desk top review of evidence supplied by Dr Dr C Dahs and Dr I P Humberstone for areas within the key question Safe. This review was completed on 20 December 2016.

Upon review of the documentation provided by the practice, we found the practice to be good in providing safe services. Overall, the practice is rated as good.

The practice was previously inspected on 17 February 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated good overall. However, within the key question safe several areas were identified as requires improvement, as the practice was not meeting the legislation to meet Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe Care and Treatment

At the inspection in February 2016 we found that the registered person did not assess and mitigate against risks as they had not risk assessed the need for Disclosure and Barring Service (DBS) checks for chaperones. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

Other areas identified where the practice was advised they should make improvements included:

• Reviewing or risk assessing arrangements for medical emergencies to ensure that equipment and medicines are in place.
• Reinstating Patient Participation Group (PPG) meetings, in order to identify and act on patients’ feedback and suggestions about the service.
• Conducting patient surveys as a means of obtaining patient feedback.
• Preparing a business continuity plan to be ready for any interruptions to service.
• Conducting regular fire evacuation drills in line with the fire risk assessment.

The practice supplied CQC with evidence of the action they would take after the inspection in February 2016. For this desk top review they provided a range of documentation which demonstrated they are now meeting the requirements of Regulation 12 Staff Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice also demonstrated improvement in the other areas identified in the report from February 2016 which did not affect ratings. These improvements have been documented in the well-led section, showing how the practice has demonstrated continuous improvement since the inspection in February 2016.

The area where the practice should continue to make improvements are:

• Formalise the processes in place to protect patients by completing a written risk assessment for staff who act as chaperones who are not DBS checked, including updating the chaperone policy to reflect amended procedures.

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 Dr Dahs & Dr I P Humberstone Cranham Village 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 to safety and 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. 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.
• Not all staff who acted as chaperones had received a Disclosure and Barring Service (DBS) check.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that 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 improvement are:

• To ensure that staff acting as chaperones undergo Disclosure and Barring Service checks or to risk assess the need.

The areas where the provider should make improvement are:

• To review arrangements for medical emergencies to ensure that equipment and medicines are in place or to risk assess the need.

• To reinstate Patient Participation Group (PPG) meetings, in order to identify and act on patients’ feedback and suggestions about the service.

• To conduct patient surveys as a means of obtaining patient feedback.

• To prepare a business continuity plan to be ready for any interruptions to service.

• To conduct regular fire drills.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We reviewed the information available to us about Dr C Dahs & Dr IP Humberstone on 22 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.