A legionella risk assessment had been completed and an action plan to mitigate the risks identified had been implemented.

The practice had carried out a fire drill and had undertaken regular fire alarm maintenance testing as a requirement identified in their fire risk assessment.

A system to monitor and manage staff training had been implemented.

All staff had received an appraisal with the exception of the practice manager and the assistant practice manager. A date was planned for these to be completed in July 2017.

Policies and procedures were signed and dated and all had been reviewed in the last six months. Evidence was seen that staff were mostly following these policies. All staff had received infection prevention and control (IPC) training as specified in their infection control policy. However, reception staff we spoke with who performed chaperone duties were not following the chaperone policy as they differed in their account of who recorded the event in the medical record.

Recruitment procedures had been reviewed and appropriate checks completed for all staff and locum GPs including Disclosure and Barring Service (DBS) checks for two practice nurses who had been appointed following the practice’s registration with CQC.

We saw evidence a system to monitor clinical staff’s registration with the professional bodies had been implemented.

A process to obtain a complete record of the immunity status of clinical staff as specified in the national Green Book (Immunisations Against Infectious Disease) guidance for healthcare staff had been commenced.

The approved health and safety poster was displayed in the staff area which identified the local health and safety representative.

The practice had completed an audit of broad spectrum antibiotic prescribing to ensure appropriate prescribing.

A system to record the number of prescription boxes containing blank prescriptions received into the practice had been implemented to monitor and track blank prescriptions as specified in NHS Protect Security of Prescriptions (2013) guidance.

A schedule of monthly team meeting dates had been developed. Staff told us they had the opportunity to raise any issues at team meetings and felt confident and supported in doing so.

We saw evidence complaints had been discussed at the full team meeting to share learning with staff.

The practice manager told us the practice were in the process of reviewing ways to engage with patients and had recently recruited one member to the patient participation group (PPG).

All staff who perform chaperone duties should be aware of and follow the procedures specified in the practice’s chaperone policy.

Ensure the practice management team staff receive an appraisal.

Consider reviewing and developing ways to engage with patients further. For example, by developing a practice website and to continue to promote the patient participation group.

A legionella risk assessment had been completed and an action plan to mitigate the risks identified had been implemented.

The practice had carried out a fire drill and had undertaken regular fire alarm maintenance testing as a requirement identified in their fire risk assessment.

A system to monitor and manage staff training had been implemented.

All staff had received an appraisal with the exception of the practice manager and the assistant practice manager. A date was planned for these to be completed in July 2017.

Policies and procedures were signed and dated and all had been reviewed in the last six months. Evidence was seen that staff were mostly following these policies. All staff had received infection prevention and control (IPC) training as specified in their infection control policy. However, reception staff we spoke with who performed chaperone duties were not following the chaperone policy as they differed in their account of who recorded the event in the medical record.

Recruitment procedures had been reviewed and appropriate checks completed for all staff and locum GPs including Disclosure and Barring Service (DBS) checks for two practice nurses who had been appointed following the practice’s registration with CQC.

We saw evidence a system to monitor clinical staff’s registration with the professional bodies had been implemented.

A process to obtain a complete record of the immunity status of clinical staff as specified in the national Green Book (Immunisations Against Infectious Disease) guidance for healthcare staff had been commenced.

The approved health and safety poster was displayed in the staff area which identified the local health and safety representative.

The practice had completed an audit of broad spectrum antibiotic prescribing to ensure appropriate prescribing.

A system to record the number of prescription boxes containing blank prescriptions received into the practice had been implemented to monitor and track blank prescriptions as specified in NHS Protect Security of Prescriptions (2013) guidance.

A schedule of monthly team meeting dates had been developed. Staff told us they had the opportunity to raise any issues at team meetings and felt confident and supported in doing so.

We saw evidence complaints had been discussed at the full team meeting to share learning with staff.

The practice manager told us the practice were in the process of reviewing ways to engage with patients and had recently recruited one member to the patient participation group (PPG).

All staff who perform chaperone duties should be aware of and follow the procedures specified in the practice’s chaperone policy.

Ensure the practice management team staff receive an appraisal.

Consider reviewing and developing ways to engage with patients further. For example, by developing a practice website and to continue to promote the patient participation group.