Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 6 September 2016. The overall rating for the practice was good with requires improvement for safety. The full comprehensive report for the  inspection of 6 September 2016 can be found by selecting the ‘all reports’ link for Bawtry and Blyth Medical on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 6 September 2016. 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.

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

• There was an effective system in place for reporting and recording significant events including capturing near misses in the dispensary.

• The practice introduced a controlled drugs register in October 2016. Monthly checks of stocks of medicines, including controlled drugs, were now completed and recorded on the electronic system and records retained in the dispensary.

• We were shown the procedure implemented to share medicine alerts with dispensary staff. Actions taken as a result of the alert were documented in the action log which was available to all staff on the shared computer drive.

• The practice had reviewed and updated the dispensary standard operating procedures.

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 Bawtry and Blyth Medical on 6 September 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. We noted investigations of incidents did not include routine review of the relevant policy or procedure.
• Most risks to patients were assessed and managed. An infection prevention and control audit had not been completed in the last two years.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and 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 improvement are: 

• Ensure the controlled drugs register meets the requirements set out in The Misuse of Drugs Regulations 2001 (and subsequent amendments) and regular checks of stock completed and documented.

The areas where the provider should make improvement are:

• Review the incident reporting process to include review of relevant policy or procedure during the investigation process.
• Consider implementing a procedure to capture ‘near misses’ in the dispensary which contributes to the practice incident reporting process.
• Complete an infection prevention and control audit of the main surgery and branch and act in accord with the findings.
• Review the procedure for sharing medicine alerts with dispensary staff so they have sight of them and actions taken.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice