Letter from the Chief Inspector of General Practice

We carried out a desk top review of Felmores Surgery on 6 October 2016. This was to check the practice had addressed areas for improvement highlighted during their earlier announced comprehensive inspection conducted on 8 June 2016. At this inspection the practice was rated as good overall, good for effective, caring, responsive and well led domains. The safe domain was rated as requires improvement.

During our last inspection we found the provider had not undertaken DBS checks for staff undertaking chaperone duties and did not have a risk assessment in place as to why one was unnecessary. The provider was asked to remedy these and a requirement notice for these improvements was issued.

The provider was also advised they should take action in the following areas;

• Ensure the recording, analysis and actions for a significant event are fully documented and learning revisited ensure improvements have been maintained.
• Ensure cleaning schedules can demonstrate the type and frequency of the cleaning required for the rooms and equipment.
• Ensure clinical audits have sufficient narrative to identify learning and how this has been embedded to improve practice.
• Ensure records of discussions, decisions and actions are appropriately documented and shared amongst the practice team. Actions should be revisited to ensure tasks are completed and learning embedded into practice. 

After the inspection report was published the provider sent us an action plan that detailed how they would make the necessary improvements. We were then provided with documentary evidence of the improvements they had made. We were able to carry out a desk top inspection without the need to visit the practice.

During this desk top inspection, we reviewed documents that demonstrated that all staff now had appropriate DBS checks in place including those required to undertake chaperone duties. We found their recording, investigation, analysis and sharing of learning had improved and had been documented. They had revised their cleaning schedules and provided a narrative analysis to their clinical data and how it had informed and improved clinical performance. 

We were satisfied that the practice had made the required improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a desk top review of Felmores Surgery on 6 October 2016. This was to check the practice had addressed areas for improvement highlighted during their earlier announced comprehensive inspection conducted on 8 June 2016. At this inspection the practice was rated as good overall, good for effective, caring, responsive and well led domains. The safe domain was rated as requires improvement.

During our last inspection we found the provider had not undertaken DBS checks for staff undertaking chaperone duties and did not have a risk assessment in place as to why one was unnecessary. The provider was asked to remedy these and a requirement notice for these improvements was issued.

The provider was also advised they should take action in the following areas;

• Ensure the recording, analysis and actions for a significant event are fully documented and learning revisited ensure improvements have been maintained.
• Ensure cleaning schedules can demonstrate the type and frequency of the cleaning required for the rooms and equipment.
• Ensure clinical audits have sufficient narrative to identify learning and how this has been embedded to improve practice.
• Ensure records of discussions, decisions and actions are appropriately documented and shared amongst the practice team. Actions should be revisited to ensure tasks are completed and learning embedded into practice. 

After the inspection report was published the provider sent us an action plan that detailed how they would make the necessary improvements. We were then provided with documentary evidence of the improvements they had made. We were able to carry out a desk top inspection without the need to visit the practice.

During this desk top inspection, we reviewed documents that demonstrated that all staff now had appropriate DBS checks in place including those required to undertake chaperone duties. We found their recording, investigation, analysis and sharing of learning had improved and had been documented. They had revised their cleaning schedules and provided a narrative analysis to their clinical data and how it had informed and improved clinical performance. 

We were satisfied that the practice had made the required improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection on 15 November 2013, we saw that the service was not accessible for children under 16 years of age unless they were accompanied by a parent or guardian.

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms. People told us that staff always asked for their consent before they performed any treatment or procedure.

Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided. People told us that their treatment was clearly explained to them and they were able to ask questions and make choices.

The people we spoke with were happy with the service and did not have any concerns or issues about the care and treatment they received. There were adequate systems in place to ensure records were accurate and maintained.