Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dearden Avenue Medical Practice on 28 October 2014. The overall rating for the practice was good however there were improvements required in the key question safe. We also carried out an announced focussed inspection on 16 February 2017. At this inspection we found that although the practice had made some improvements there was still improvement to be made in providing safe services. Overall, the practice was rated as good. The full comprehensive report on the 28 October 2014 inspection and the announced focussed report from the 16 February 2017 inspection can be found by selecting the ‘all reports’ link for Dearden Avenue Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 July 2017 to confirm 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 inspections. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings at this inspection were as follows:

• We reviewed a range of documents which demonstrated they were now meeting the requirements of Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance, and Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Fit and proper persons employed.
• Recruitment folders were in place for staff and all staff had an up to date Disclosure and Barring Service (DBS) check in place and recruitment files contained all relevant information as stated in schedule three of the Health and Social Care Act.
• We found that the practice had a system in place for documenting significant events and all significant events were now recorded.
• Practice policies and procedures were in place, in particular those for infection control, and were easily accessible for staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This was a focused inspection of Dearden Avenue Medical Practice in one area within the key question safe. The evidence was reviewed at Dearden Avenue Medical Practice.

At this inspection we found that although the practice had made improvements in some areas other improvements were still required in providing safe services. Overall, the practice is rated as good.

The practice was previously inspected on 28 October 2014. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection, the practice was rated good overall but required improvement for providing safe services.

Our key findings were as follows:

• At the inspection on 16 February 2017 we reviewed a range of documents and found that some of the required improvements had been made.
• Recruitment folders were in place for staff and all staff had an up to date Disclosure and Barring Service (DBS) check in place.
• The practice was holding regular team meetings and minutes of these were available.
• We found that the practice had a system in place for documenting significant events but there was an example of a significant event not being recorded.
• Infection control policies were in place but were not being followed and staff members struggled to locate these when we requested them.

The areas where the provider must make improvements are:

• Ensure all significant events are reported.
• Ensure recruitment files contain relevant information as stated in schedule three of the Health and Social Care Act.

The areas where the provider should make improvements are:

• All policies should be followed and easily accessible to staff.

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 Dearden Avenue Medical Practice on 28 October 2014. The overall rating for the practice was good however there were improvements required in the key question safe. We also carried out an announced focussed inspection on 16 February 2017. At this inspection we found that although the practice had made some improvements there was still improvement to be made in providing safe services. Overall, the practice was rated as good. The full comprehensive report on the 28 October 2014 inspection and the announced focussed report from the 16 February 2017 inspection can be found by selecting the ‘all reports’ link for Dearden Avenue Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 July 2017 to confirm 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 inspections. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings at this inspection were as follows:

• We reviewed a range of documents which demonstrated they were now meeting the requirements of Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance, and Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Fit and proper persons employed.
• Recruitment folders were in place for staff and all staff had an up to date Disclosure and Barring Service (DBS) check in place and recruitment files contained all relevant information as stated in schedule three of the Health and Social Care Act.
• We found that the practice had a system in place for documenting significant events and all significant events were now recorded.
• Practice policies and procedures were in place, in particular those for infection control, and were easily accessible for staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice