We carried out an announced comprehensive inspection at Dr Suares Practice on the 10th November 2015. The overall rating for the practice was good and Safe required improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Dr Suares on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 31 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 10 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 19 HSCA of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Fit and Proper Person Employed.

Our key findings were as follows:

• The practice had addressed the issues identified during the previous inspection.

• They had updated their recruitment policy and took all actions necessary when carrying out required recruitment checks for newly appointed staff.

• They reviewed incidents of risk and complaints with all staff to help improve shared learning within the practice and to help staff understanding of any lessons learnt.

• They had updated staff training including safeguard training for all staff in regard to vulnerable adults and children. Training records had been updated to include evidence of all necessary training carried out by each member of staff.

• They updated their fire risk assessment and ensured that they had clear arrangements in place for managing all aspects of fire safety within the practice.

• Policies and procedures had been reviewed and updated to ensure they provided up to date and necessary guidance for staff.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Suares on the 10th November 2015. Overall the practice is rated as good.

Our key findings were as follows:

• Clinical staff regularly reviewed significant events although there was no formal system to share learning amongst the whole staff team to identify and learn from events.

• The practice had a safeguard lead and staff were aware of how to report patients considered at risk. The practice staff advised they would introduce fire safety checks. However there were gaps in staff training where some staff had not received safeguard training for vulnerable adults.

• Some aspects of managing safety needed further review as the practice did not have a formal fire risk assessment although they did have various fire safety checks in place for managing risks. The practice had an oxygen cylinder but we found that it was not securely stored to the wall and had no signage for the room it was stored in. The practice staff advised they would introduce fire safety checks and ensure the oxygen cylinder would be secured to the wall with clear sign posting of were its located.

• Staff files were mainly organised and had appropriate checks in place apart from one staff file. This file lacked any evidence of safe recruitment checks such as: references; medical review; interview notes and no evidence of a DBS check. Following our visit the practice have advised that necessary recruitment checks will be in place for all staff.

• The practice was clean and tidy.

• The clinical staff proactively sought to educate patients to improve their lifestyles by regularly inviting patients for health assessments.

• Patients spoke highly about the practice and the whole staff team. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice has a Patient Participation Group (PPG) who regularly met with the practice staff. They made suggestions throughout the year to help improve the service provided by the practice.

• Information about the services provided and how to complain was available at the practice. Complaint records had detailed information to show how they had been investigated.

• Staff had delegated duties assigned to them. Staff felt supported by the GPs and the external business team supporting them since the practice manager had left the practice. The practice staff advised that a new full time practice manager would be appointed. Staff felt well trained however training records had gaps and were in need of being updated to reflect the training staff had carried out.

There were areas of practice where the provider must make improvements.

• Take action to ensure its recruitment policy, procedures and arrangements are improved to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held. Health and Social Care Act 2008 Fit and Proper Person Employed. (Regulated Activities) 2014 Regulations 19 1)2)4)5).

There were areas of practice where the provider should make improvements.

Action the provider should take to improve:­­­

• To ensure all serious incidents of risk and complaints are shared with all staff to help improve shared learning within the practice and to help staff understanding of any lessons learnt.

• To ensure safeguard training is available and provided for all staff in regard to vulnerable adults and children and ensure staff are updated in the level of training

• To provide an updated fire risk assessment that ensures clear arrangements are in place for managing all aspects of fire safety within the practice.
• To review training records to ensure that all staff have evidence of updated training relevant to their role.
• To review all policies and procedures to ensure they are up to date with necessary guidance for staff.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Pilch Lane Surgery on 13 June 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.