Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Capelfield Surgery on 21 January 2016. The overall rating for the practice was good, but breaches of legal requirements were found in the safe domain. The practice sent to us an action plan detailing what they would do in relation to the shortfalls identified and the action taken in order to meet the legal requirements in relation to the following:-

• The practice did not have a system for production of Patient Specific Directions to enable Health Care Assistants to administer vaccinations after specific training when a doctor or nurse were on the premises.
• Clinical specimens were seen to be stored in the same fridge as medicines which does not comply with the Public Health England Protocol for ordering, storing and handling vaccines.
• Printer prescription paper was not monitored within the practice and large quantities of prescription paper were observed left in printers with the rooms left unlocked.
• The practice was unable to provide evidence that an evacuation drill had been carried out.
• There was a wall mounted mercury sphygmomanometer, an instrument used for measuring blood pressure, in one room but there was no mercury spill kit on site.
• The practice could not provide proof that all clinicians had received Mental Capacity Act (MCA) and deprivation of liberties (DoLs) training.

The full comprehensive report on the 21 January 2016 inspection can be found by selecting the ‘all reports’ link for Capelfield Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 March 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 21 January 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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

• The practice now had a system in place for the production of Patient Specific Directions.
• The practice no longer stored specimens in the vaccine fridge.
• Printer prescription paper was now stored in a locked cupboard and a system for monitoring it throughout the practice introduced.
• A fire evacuation drill had been carried out and recorded.
• The mercury containing instrument had been removed.
• All clinical staff had received Mental Capacity Act and Deprivation of Liberty training.

Additionally we saw that:

• Staff had been trained in adult safeguarding and basic life support.
• The practice had a recruitment policy in place, but had not employed any new staff since the previous inspection.
• However the procedure for registering a new manager and the regulated activity ‘maternity and midwifery’ had not yet been completed.

The areas where the provider should make improvement are to:

• Ensure that the process to register a manager with CQC is completed.
• Ensure that all regulated activities being provided are registered with CQC including maternity and midwifery.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Capelfield Surgery on 21 January 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 assessed and well managed.
• 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 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 improvement are:

• Ensure Person Specific Directions (PSD) are in place for the health care assistant. A Patient Specific Direction (PSD) is the written instruction, signed by a doctor, for medicines to be administered to a named patient after the patient has been assessed on an individual basis.

• Ensure that only medicines are stored in the medicine fridge. Specimens must not be stored in the same fridge as medicines.

• Ensure that prescription paper is stored securely and monitored within the practice.

• Ensure that when fire drills are regular and include evacuation drills.

• Ensure that there is a mercury spill kit on site if instruments containing mercury remain on site.

• Ensure that all staff have an awareness of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

The areas where the provider should make improvement are:

• Ensure that the process to register a manager with CQC is completed.

• Ensure that all regulated activities being provided are registered with CQC including maternity and midwifery.

• Ensure that all staff complete adult safeguarding and basic life support training.

• Ensure that the recruitment process and checks are robust and appropriate records kept.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice