Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr P and S Poologanathan on 15 March 2015. The overall rating for the practice was good, however we rated the practice as requires improvement for providing safe services based on our findings which included lack of infection control training and legionella testing. The full comprehensive report on the 18 March 2015 inspection can be found by selecting the ‘all reports’ link for Dr P and S Poologanthan’s surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 6 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 15 March 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection we found that the issues found during the previous inspection had been addressed. Therefore, the practice is now rated as good for providing safe services.

Our key findings across the areas we inspected for this focused inspection were as follows:

• We found that the infection control lead had undertaken infection control training and audits were now carried out at six monthly intervals.

• We saw that learning from significant events was shared with non-clinical staff during practice meetings.

• Legionella testing was carried out by an external organisation and possible hazards identified had been actioned and appropriate records were maintained.

• We found that all staff who acted as chaperones were suitably trained.

• The practice nurse was aware of and could sufficiently articulate the Gillick competencies.

• The practice had a fire risk assessment and carried out fire drills annually.

• Clinical audits we looked at demonstrated that improvements had been made to ensure any negative results were addressed.

The area where the provider should make improvement is:

• The practice should review their fire risk assessment to ensure it is detailed and reflective of the practice’s current arrangements.

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 Dr P and S Poologanathan's practice on 18 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. The practice requires improvement for providing safe services. It was also good for providing services for older people, people with long term-conditions, families, children and young people, the working age (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• 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 areas where the provider must make improvements are:

• Ensure appropriate standards of cleanliness and hygiene in relation to the premises occupied for the purpose of carrying out the regulated activity are met. To ensure the leads for infection control undertake training in infection control and are able to provide advice on the practice infection control policy and carry out staff training. Undertake infection control audits at periodic intervals.

In addition the provider should:

• Ensure learning is communicated to the wider reception team, not directly involved with a significant event and are given opportunities to raise an issue for consideration and share good practice at regular practice meetings.
• Ensure non clinical staff who undertake formal chaperone activities are suitably trained.
• Ensure a Legionella risk assessment is completed to reduce the risk of infection to staff and patients.
• Ensure the monitoring of audit results to ensure any negative results are addressed.
• Ensure a fire risk assessment is completed to maintain fire safety.
• The practice nurse to be aware of the Gillick competencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice