Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 7 October 2014. We found the practice was in breach of legal requirements. The breaches related to regulation 9 (Care and welfare) and 13 (Management of medicines) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponded to regulation 12 (Safe care and treatment) and regulation 15 (Premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches.

We undertook this focused inspection on 30 September 2015 to check that they had followed their plan and to confirm that they now met the 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 for Drs K Conod, S Caddy & S Garsed on our website at www.cqc.org.uk

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns such as safeguarding, and to report incidents, including significant events.
• Systems were in place to ensure the safe storage of vaccinations and patient samples.
• Infection control procedures were in place but systems to monitor and maintain standards should be improved.
• Emergency medicines and medical equipment were managed safely and staff were aware of their roles in the event of a medical emergency.
• Non clinical staff did not have a disclosure and barring service (DBS) check or risk assessment in place to determine if a DBS check was required.
• There were plans in place to ensure the practice could still operate in the event of a major incident and staff we spoke with were aware of the plans.

However, there were also areas of practice where the provider needs to make improvements.

In addition the provider should:

• Risk assess staff who do not have a disclosure and barring service (DBS) check in place.
• Develop robust system to monitor and maintain standards of cleanliness within the general environment and ensure all actions from the recent infection control audit are completed including infection control training for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Drs K Conod, R Jarrams & S Caddy is also known as The Limes Medical Centre. Overall the practice is rated as good.

Specifically we found the practice requires improvement for safe services but was good for providing effective, responsive, caring and well led services. The practice was found to be good for the services it provided to all population groups.

Our key findings were as follows:

• Emergency medicines and medical equipment were not managed safely and not all staff were aware of their roles in the event of a medical emergency.

• The practice had effective procedures in place that ensure care and treatment was delivered in line with appropriate standards.

• Patients were treated with dignity and respect. Patients spoke very positively of their experiences and of the care and treatment provided by staff.

• The practice was responsive to patients’ needs and provided services that reflected the needs of the patients.

• We found that the service was well led overall. The practice engaged with the patient population and made changes to service where appropriate as a result of their feedback.

Areas of practice where the provider needs to make improvements are:

The provider must:

• Ensure medication management systems are robust.

• Ensure emergency medical equipment is in date and checked regularly to ensure it is safe and in working order.

In addition the provider should:

• Ensure DBS checks or appropriate risk assessments are carried out for staff who assume the role of a chaperone.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We visited the surgery to establish that the needs of people using the service were being met. On the day of the inspection we spoke with ten patients, five staff members, two GPs and the practice manager. The patients we spoke with were all complimentary about the service. One patient said, “The staff go out of their way to help”.

Patients told us that they received care, treatment and support that met their needs. One patient said, “The doctor gives me the information I need; they put my mind at rest”.

Staff must be appropriately supported, trained and supervised in delivering care and treatment to patients who used the service. Staff told us they had annual appraisals and the training they required. One staff member told us they were given regular feedback on their performance.

As part of the inspection we spoke with the Patient Participation Group (PPG). PPGs are an effective way for patients and GP surgeries to work together to improve the service and to promote and improve the quality of the care. They told us they supported the practice in obtaining feedback from their patients.