Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Hawthorns Surgery on 25 February 2016. The overall rating was good. During the inspection we found breaches of legal requirements and the provider was rated as requires improvement under the safe key question. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensuring that there is regular testing of water supply temperatures in order to minimise the risk of exposure of staff and patients to Legionella bacteria.
• Ensuring the timely review of all documents, patient reports and correspondence received by the practice in order to promote safe outcomes for patients.

The full comprehensive report on the 25 February 2016 inspection outcome can be found by selecting the ‘all reports’ link for The Hawthorns Surgery on our website at www.cqc.org.uk.

An announced focused inspection was carried out on 28 March 2017. This inspection was to verify if the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 25 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our previous inspection on 25 February 2016, we rated the practice as requires improvement for providing safe services as water temperatures were not being monitored in accordance with the Legionella risk assessment and correspondence received by the practice was not being actioned in a timely manner. At this inspection we found that the practice had completed their action plan and the practice is now rated as good for providing safe services.

Our key findings at this inspection, 28 March 2017 were as follows:

• Water temperatures were being monitored regularly in accordance with the Legionella risk assessment.
• The practice had implemented a system to ensure there was clear responsibility for handling correspondence and to ensure that it was reviewed and dealt with in a timely manner.

At our previous inspection on 25 February 2016, we also found that the arrangements for the storage of clinical waste awaiting collection could be improved.

During our inspection 28 March 2017 we saw;

• The practice had improved the arrangements for clinical waste to ensure that it was stored securely prior to collection.

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 Hawthorns Surgery on 25 February 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.
• Risks to patients were generally assessed and well managed. However, the practice had not taken steps to minimise the risk of exposure to Legionella bacteria.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Systems in place did not always ensure the timely review of all documents, patient reports and correspondence received by the practice.
• 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 they found it easy to make an appointment with a named GP and that 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 must make improvements are:

• Ensure regular testing of water supply temperatures in order to minimise the risk of exposure of staff and patients to Legionella bacteria.
• Ensure the timely review of all documents, patient reports and correspondence received by the practice in order to promote safe outcomes for patients.

The areas where the provider should make improvements are:

• Ensure improved arrangements for the safe and secure storage of clinical waste awaiting collection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice