Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Spa Surgery on 14 July 2015. The overall rating for the practice was good. However; we rated the practice as requires improvement for providing safe care The full comprehensive report on the July 2015 inspection can be found by selecting the ‘all reports’ link for Spa Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the issues that we identified in our previous inspection on 14 July 2015. This report covers our findings in relation to those requirements.

The practice has now met the legal requirements in the key question of safe and is now rated as good.

Our key findings were as follows:

• Risks to patients were assessment and well managed. The practice had implemented Disclosure and Barring Service (DBS) checks for all clinical staff and those acting in the role of a chaperone. Risk assessments were in place for all non-clinical staff to outline why a DBS check had not been conducted.
• The practice had carried out risk assessments in relation to fire; health and safety and legionella. Actions identified as a result of the assessments had been addressed.
• We reviewed the staff files of two recently recruited staff members and found appropriate checks had been undertaken.

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 Spa Practice on 14 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for all the population groups. It required improvement for providing safe services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Staff told us they had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• Patients said there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by the partnership. The practice proactively sought feedback from staff and patients, which it acted on.
• Some risks to patients were assessed and managed, with the exception of those relating to recruitment checks and legionella testing

However, there were areas of practice where the provider should make improvements.

• Ensure recruitment arrangements include all necessary pre-employment checks.
• Ensure a legionella test is completed and action plan implemented in accordance with the findings.
• Ensure risk assessments are appropriately documented and recorded and updated as necessary.
• Keep a record of all training and updates staff attend.
• Comply with fire safety regulations by performing fire evacuation drills as required.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We reviewed the information available to us about Spa Surgery on 12 April 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.