Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at The Lennard Surgery on 15 December 2016 to check if improvements had been made in response to our previous comprehensive inspection on 29 September 2015.

On 29 September 2015 we found the practice required improvement in the safe domain and was rated by us as good for effective, caring, responsive and well-led domains. Overall the practice was rated as good. We issued a requirement notice with regards to the breach of Regulation 19 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Fit and proper persons employed:

• The requirement notice was for the provider to make improvements to ensure recruitment arrangements included all necessary employment checks for all staff. During our inspection we saw personnel employed to carry on the regulated activity did not have the appropriate checks through the Disclosure and Barring Service or risk assessments to identify they were not required. The practice did not hold the required specified information in respect of persons employed by the practice as listed in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In addition we told the provider they should:

• Evidence that action plans were implemented and completed to rectify concerns found during infection control audits.
• Have a system of recording comments / verbal complaints made to the service for audit purposes.
• Continue to develop a system of clinical audits and re-audits to improve patient outcomes.
• Have a risk assessment and policy for the management, testing and investigation of legionella (a bacterium which can contaminate water systems in buildings).

A copy of the report detailing our findings can be found at www.cqc.org.uk.

Our key findings across the areas we inspected on 15 December 2016 were as follows:

• There was a system to ensure appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, references, qualifications, registration with the appropriate professional body and the appropriate checks through the Disclosure and Barring Service.
• Infection prevention and control systems for healthcare-associated infection were in place.
• The practice assessed, planned and effectively managed potential risks to the service from fire.
• The practice monitored patient care and treatment outcomes through clinical audits and re-audits.
• There was a system to record and respond to patient verbal complaints and concerns.

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 The Lennard Surgery on 29 September 2015. 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 assessed and well managed, with the exception of those relating to recruitment checks and the management of legionella.
• 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.
• 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 recruitment arrangements include all necessary employment checks for all staff.

In addition the provider should:

• There should be evidence that action plans were implemented and completed to rectify concerns found during infection control audits.

• The practice should have a system of recording comments / verbal complaints made to the service for audit purposes.

• Continue to develop a system of clinical audits and re-audits to improve patient outcomes.

• The practice should have a risk assessment and policy for the management, testing and investigation of legionella (a bacterium which can contaminate water systems in buildings).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice