Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Oughtibridge Surgery on 1 June 2016. The overall rating for the practice was good with requires improvement in well led. The full comprehensive report from 1 June 2016 can be found by selecting the ‘all reports’ link for Oughtibridge Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 13 March 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 1 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good. Specifically, following the focused inspection we found the practice to be rated good for being well led.

Our key findings were as follows:

• The practice had implemented a system to monitor and track blank prescriptions within the practice.

• We saw evidence staff were following practice policies.

• We saw evidence risk assessments had been monitored and reviewed. For example, fire and legionella risk assessments had been updated.

• The practice had completed a risk assessment of staff who performed chaperone duties and staff who had direct patient contact who had not received a DBS check. A rolling programme to complete this by the end of March 2017 had been implemented. The practice provided evidence following the inspection that these had been completed or applied for. (DBS 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 children or adults who may be vulnerable).

• The practice had completed a risk assessment to ensure the appropriate emergency drugs were available to staff in a central location in an emergency.

• A risk assessment of the security of the dispensary and access to the controlled drug cupboard key had been completed.

• Training updates for the practice nurses and competency assessments of dispensary staff had been completed.

• The practice had an up to date record of clinical staffs’ immunity status as specified in the national Green Book (immunisations against infectious disease) guidance for healthcare staff.

• The practice had installed a thermometer in the dispensary to monitor the ambient room temperature to ensure drugs were stored at temperatures specified in national guidance.

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 Oughtibridge Surgery on 1 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Staff told us they would be made aware of procedure changes by the practice manager if it was relevant to their role.
• Most risks to patients were assessed although there were shortfalls in management monitoring and governance in some areas.For example, recruitment, health and safety and medicines management.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Implement a system to monitor and record the movement of blank prescriptions and pads within the practice as outlined in NHS Protect Prescription Security Guidance. Make secure blank prescriptions stored in the dispensary and in printers when rooms are not in use.

• Complete a risk assessment of the security of the dispensary when dispensary staff are not on duty and review who has access to the controlled drug cupboard key.

• Ensure all staff who have direct patient contact receive a disclosure and barring service (DBS) check. (DBS 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 children or adults who may be vulnerable).

• Implement a risk assessment for legionella to ensure the current actions being taken are adequate to monitor the risks (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

• Review and monitor the fire risk assessment to ensure it is current and carry out regular fire drills.

• Complete a risk assessment of emergency medicines available to practice staff to use in a medical emergency. Review the storage of these medicines and ease of access during an emergency.

• Implement a system to ensure staff receive training updates relevant to their role. Include vaccination update training for practice nurses and competency assessment of dispensing staff and reception staff who perform second person checks when dispensing medication.

• Maintain 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.

The areas where the provider should make improvement are:

• Monitor the ambient room temperature of the dispensary to ensure drugs are stored under 25 degrees centigrade as per national guidance.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice