Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Leen View Surgery on 12 April 2016. During that inspection we found that non-clinical staff who undertook chaperone duties had not received a disclosure and barring service (DBS) check, and a risk assessment had not been completed to determine whether this was required.

Also, the recruitment policy did not include reference to all information required by law when recruiting new members of staff. The practice had not obtained assurances that locum doctors who worked there had undergone all required recruitment checks through their employment agency. Effective systems were not in place to oversee and improve some aspects of the quality and safety of the services provided.

Overall the practice was rated as good with are services safe and well-led requiring improvement in view of the above.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Leen View Surgery on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice told us what action they had, and were taking to meet the legal requirement in relation to the breaches.

We undertook a focused inspection on 27 October 2016 to check that the provider had completed the required action, and now met the legal requirements. We visited the practice as part of this inspection.

This report covers our findings in relation to the above requirements.

This inspection found that the provider had taken appropriate action to meet the legal requirements.

• All staff carrying out chaperone duties had received a disclosure and baring service check. (These 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 vulnerable children or adults).
• Effective recruitment procedures were followed to ensure the practice obtained the required information and checks prior to new staff working at the practice.
• A protocol was in place to obtain assurances that locum doctors who work at the practice had undergone required recruitment checks through their employment agency. Two locum doctors files we checked contained copies of the required checks and information.

• Effective systems were in place to oversee and improve the quality and safety of the services provided, and to reduce risks to patients.    

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 Leen View Surgery on 12 April 2016. Overall the practice is rated as requires improvement.

• Some risks to patients were assessed and managed. This included safeguarding children and vulnerable adults and the management of medicines. We found exceptions however in relation to administrative staff undertaking chaperone duties without disclosure barring service (DBS) checks or a suitable risk assessment being undertaken to determine whether this was needed. Also, locum doctors had worked in the practice without assurance they had been subject to appropriate vetting procedures.
• The provider was performing in line with the Quality and Outcomes Framework (QOF) with low exception rate reporting.
• There was evidence that staff assessed patients’ needs and delivered care in line with current evidence based guidance. A number of clinical audits had been carried out, but needed strengthening to show improvements in patient care and treatment.
• The practice worked effectively with community based staff, but needed to improve information recording.
• A number of patients said they were treated with compassion, dignity and respect, and nurse led care was rated highly by patients. Feedback also showed however that not all people felt cared for, supported and listened to by their GP.
• The practice had identified a small number of carers within the practice, and more efforts were required to identify with this group.
• Information about services and how to complain was available and easy to understand. The provider responded to complaints received. The provider did not however, undertake an evaluation of complaints received to improve the quality of services delivered.
• The practice had good facilities in a modern building and was well equipped to treat all patient needs.

• There was a leadership structure in place and evidence that staff felt supported by management. Practice management supported staff development and was committed to improve its service provided. However, leadership and governance was not sufficiently robust and did not always identify the risks to patients.

The area where the provider must make improvements are:

• Identify, assess and mitigate risk in relation to non clinical staff undertaking chaperone duties and obtain assurance to demonstrate that locum doctors have undergone appropriate vetting procedures.

• Improve the governance procedures in place at the practice to identify and manage risks.

In addition the provider should:

• Review the frequency of infection control audits.

• Review the recruitment policy to include reference to all documentation and information required by law when recruiting new members of staff

• Consider maintaining more detailed records of practice meetings held with multidisciplinary teams, and any other attached staff to the practice.

• Take more proactive steps to improve the identification of carers.

• Consider strengthening clinical audits to demonstrate improvements in patient care.

• Consider the low patient satisfaction results in respect of GP consultations and access to the service and identify improvement areas.

• Undertake a subsequent analysis of all complaints received to ensure that learning points, corrected actions and trend analyses have been implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice