Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Mounts Medical Centre on 7 October 2015. The overall rating for the practice was Good however a breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to:

• Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

The full comprehensive report of the inspection on 7 October 2015 can be found by selecting the ‘all reports’ link for The Mounts Medical Centre on our website at www.cqc.org.uk .

This inspection was a desk-based focused follow up inspection carried out on 27 March 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 7 October 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as ‘Good’.

From the inspection on 7 October 2015, the practice was told they must:

• Strengthen recruitment procedures to ensure persons employed met the conditions specified in Schedule 3 for the purposes of carrying out the regulated activities. Specifically this was because appropriate pre-employment checks such as the Disclosure and Barring checks (DBS) had not been made on some clinical staff that required this check.

We also told the practice that they should make improvements to the follows areas:

• To the way they advertised how patients could complain, the availability of translation services and the support available for people who cared (carers) for others.
• To the way they appraised staff. This was because at the time of the inspection the practice had just established the management structure and not all staff had been appraised.
• To the fire risk assessment and action plans so a map of the practice was available to identify potential exit routes in the event of a fire.

Our key findings were as follows:

• We found that on 27 March 2017 the practice had made the necessary changes to their recruitment procedures and was now compliant with the requirements of Schedule 3 of Regulation 19 Health and Social Care Act (Regulated Activities) Regulations 2014, Fit and proper persons employed.
• During this inspection the practice confirmed that wall posters together with a moving ticker tape display on the patient information screen in the waiting area now gave the required information about how patients could complain, the availability of translation services and the support available for people who cared (carers) for others.
• During this inspection the practice confirmed that their appraisal process was now fully established and all staff has had an appraisal in the past 12 months.
• During this inspection the practice confirmed that they had a practice map available and accessible, this included exit routes clearly highlighted and held in the fire safety folder.

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 Mounts Medical Centre on 7 October 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 recruitment where we found appropriate checks had not been carried out.
• 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.
• Patients said they found it easy to make an appointment 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.

However, there were areas where the provider needed to make some improvements. Importantly the provider must:

• Ensure robust recruitment procedures are established and followed prior to employment of staff.

In addition, the provider should:

• Ensure information regarding the complaints procedure, translation services and carers is readily available.

• Ensure that staff appraisals are completed for all staff.

• Ensure that all actions are completed related to the fire risk assessment.

• Ensure the arrangements for business continuity in the event of a major event are updated.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice