Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at High Street Surgery on 4 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report on 4 April 2016 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• There was a clear leadership structure and staff felt supported by management. Staff were aware of the practice’s vision and strategy.
• Information about services was available and appropriate steps were taken to bring this to patient’s attention.
• Staff were aware of the practice’s policies and procedures to govern activity and they were followed.

At the inspection of 4 April 2016 there were some areas of practice where we said the provider should make improvements. We said the provider should:

• Ensure where the decision has been made not to apply for Disclosure and Barring Service (DBS) checks for staff, a risk assessment is carried out giving a clear rationale as to reasons why.

• Ensure patients are made aware of the availability of translation services.

• Ensure staff read all policies that apply to their job role.

• Review and update procedures and guidance in particular those that relate to appraisals, meetings and reviews of practice development needs to ensure staff learning needs are identified.

At this inspection we found the necessary improvements had been made. All staff had undergone a DBS check and a notice in reception made patients aware of translation services. Measures were in place to ensure all staff read practice policies and processes were in place to identify staff learning needs.

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 High Street Surgery on 4 April 2016. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Risks to patients were not fully assessed and well managed, including those relating to recruitment and background checks. Not all staff acting as chaperones had received a Disclosure and Barring Service (DBS) check. Risk assessments had not been carried out. No fire drills had been carried out since the practice opened and staff had not received suitable training. The practice had not carried out a risk assessment to consider how it would respond in the case of a medical emergency. An infection control audit had not been carried out.

• Staff said they felt supported in their roles. However, there was no formal system of appraisals, meetings and reviews of practice development needs to ensure staff learning needs were identified. Not all staff had received inductions or regular performance reviews. Staff meetings were irregular and not minuted in detail. Minutes were not shared with all staff.

• 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 was available but not everybody would be able to understand or access it. An interpreting service was available for patients who required it. However this was not brought to patients’ attention. Not all staff were aware of this service.
• The practice had a vision and a strategy but not all staff could articulate it or were clear about their responsibilities in relation to it.
• The practice had a number of policies and procedures to govern activity, but they were not followed in practice. For example in relation to staff recruitment and training.
• There was a documented leadership structure and most staff felt supported by management but at times they weren’t sure who to approach with issues.

The areas where the provider must make improvements are:

• Ensure risks related to the recruitment of staff are effectively mitigated against by following the practice policy and ensuring necessary employment and background checks are carried out, in particular where staff are acting as chaperones.
• Ensure safe recruitment processes by taking and keeping interview notes and ensuring formal inductions take place.

• Carry out a risk assessment to consider how it would respond in the case of a medical emergency in the absence of a defibrillator and a reliable source of oxygen.
• Ensure infection control audits are carried out annually.

In addition the provider should:

• Ensure where the decision has been made not to apply for DBS checks for staff, a risk assessment is carried out giving a clear rationale as to reasons why.
• Ensure patients are made aware of the availability of translation services.
• Ensure staff read all policies as apply to their job role.
• Review and update procedures and guidance in particular those that relate to appraisals, meetings and reviews of practice development needs to ensure staff learning needs are identified.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about High Street Surgery 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.