We undertook a comprehensive inspection at Dr Rachel Tomalin (Cale Green Surgery) on 25 April 2018. The overall rating for the practice was good, although the practice was rated as requires improvement for providing safe care and treatment. The full comprehensive report for the 25 April 2018 inspection can be found by selecting the ‘all reports’ link for Dr Rachel Tomalin on our website at www.cqc.org.uk.

This desk top review was carried out on 25 September 2018. We reviewed evidence submitted by the practice which demonstrated the practice had carried out their plan to meet the requirements in relation to the breach identified in relation to Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

The practice is now rated as good for providing safe care and treatment, and overall the practice is rated as good.

Our key findings were as follows:

The practice had established effective systems and processes to ensure care and treatment was provided in a safe way to patients and in accordance with the fundamental standards of care.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection April 2016 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Rachel Tomalin (Cale Green Surgery) on 25 April 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Systems and processes for safeguarding patients were not fully embedded.
• Processes for reviewing patients’ test results were not formalised or effective.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Review patient group directions to ensure they are always signed and within date.
• Review and validate QOF exception reporting figures.
• Record regular checks of the practice defibrillator.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr Rachel Tomalin, Cale Green Surgery for one area only within the key question safe.

We found the practice to be good in providing safe services. Overall, the practice is rated as good.

Dr Rachel Tomalin, Cale Green Surgery was inspected on 13 April 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection, the practice was rated ‘good’ overall. However, within the key question safe were identified as requires improvement, as the practice was not meeting the legislation in place at that time; Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the inspection in April 2016 we did not see evidence that the practice had carried out safe recruitment checks for all staff. For example, some employees had only one reference on file and two staff members in clinical roles did not have evidence that DBS checks had been undertaken. There was limited evidence that recruitment checks for locum GPs were undertaken. Some staff who carried out the role of chaperone did not have evidence available to demonstrate they had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 19 fit and proper persons employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 Rachel Tomalin, Cale Green Surgery on 13 April 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 a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained so they 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 were complimentary about the staff at the practice.
• 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 the facilities and was well equipped to treat patients and meet their needs. Some work place maintenance records were not available.
• The practice had been without a practice manager for several months and this had affected some aspects of administration. However, there was an awareness of where the practice needed to improve the services it provided and it had taken action to improve. The practice was in the process of employing a new practice manager.
• Staff felt supported by management and demonstrated a clear understanding of the leadership structure.
• The practice listened to patients however proactive engagement seeking feedback from patients had not been prioritised due to the absence of a practice manager.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff and staff who carry out the role of chaperone have a Disclosure and Barring Service check (DBS) in place.

In addition the provider should:

• Ensure a planned programme of clinical audit and re-audit is established to enable the practice to monitor care and treatment consistently and to make improvements as required quickly.
• Review the practice environmental safety to ensure appropriate risk assessments are in place; gas and electrical safety maintenance records are accessible and periodic fire safety checks are carried out.
• Ensure periodic analysis of significant events and complaints are carried out to identify themes and trends so that appropriate action can be taken if required.
• Ensure meeting minutes are stored securely and are easily accessible to all staff.
• Review and update policies, procedures and guidance.
• Actively promote and facilitate patient participation to provide feedback about the service provided by the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice