Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pelaw Medical Practice on 24 March 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 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.
• Information about services and how to complain was available and easy to understand. 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 named 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 proactively 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 should/must make improvement are:

• Repair damaged seating in reception to make it easier to clean and reduce the risk of infections being spread.
• Ensure the front fire exit and the fire assembly points are clearly marked, that there are signs directing patients to the fire assembly point from the fire exit at the rear of the building, and that all fire extinguishers are serviced.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We did not speak with patients during the course of this inspection.

At the previous inspection in March 2014 we found that the practice did not have effective recruitment procedures; this meant some members of the clinical team had commenced working with patients before required pre-employment checks had been carried out.

Following the inspection the practice sent us an action plan which included the actions they were going to take to meet the regulation and the timescale in which it would be achieved.

We returned to the practice on 9 July 2014 to see if improvements had been made. We spoke with the practice manager and checked records. We found that policies were now in place and employment checks had been carried out.

We found the provider had taken action to comply with a compliance action we set following our last inspection of Pelaw Medical Practice. During this inspection we found patients who used the service were protected from the risk of harm or abuse. Safeguarding policies and procedures had been updated or put in place, and staff had received training in how to safeguard vulnerable adult patients.

We also found the provider had taken action to comply with the other compliance action we set. They had carried out some of the required pre-employment checks for recently appointed staff. However, because the provider had not carried out all of the required pre-employment checks, this compliance action will be repeated.

Patients experienced care, treatment and support that met their needs and protected their rights. The patients we spoke with were satisfied with how practice staff listened to their views, showed them respect and involved them in decisions about their care and treatment. We found patients’ privacy was respected and promoted. One patient told us, ‘All the girls know you by name.’ Another patient told us one of the doctors had been ‘supportive and understanding’ and was ‘easy to talk to’.

Patients who used the service were not fully protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

There were effective systems in place to reduce the risk and spread of infection and the premises were clean and hygienic.

Effective recruitment and selection processes were not in place, and because of this, a member of staff was appointed who had not been subject to the required pre-employment checks.