Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Gladstone House Surgery on 11 August 2015. A breach of legal requirements was found, in that a risk assessment had not been completed to determine the risks of exposure to legionella. Overall the practice was rated as good with requires improvement for the safe domain.

After the comprehensive inspection, the practice wrote to us to say what action they had, and were taking to meet the legal requirement in relation to the breach.

We undertook a desk based review on 20 July 2016 to check that the provider had completed the required actions, and now met the legal requirement. We did not visit the practice as part of this inspection. This report covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Gladstone House Surgery on our website at www.cqc.org.uk.

Our finding across the area we inspected was as follows:

The practice had taken appropriate action to meet the legal requirement.

Overall the practice is rated good including the safe domain.

An assessment had been undertaken to determine the risks of exposure to legionella, and an action plan and control measures were in place to eliminate and control the identified risks to ensure the services were safe.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Gladstone House Surgery on 11 August 2015 Overall the practice is rated as good.

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

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff were trained to the appropriate levels for their roles and encouraged to attend training sessions to enhance their professional development.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The practice had a Carers Champion, an administrator who proactively sought to ensure that carers were identified and signposted to the appropriate places for help and guidance. Information about services and how to complain was available and easy to understand.
• 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. However learning from serious incidents were not always shared amongst the all relevant staff working at the practice.
• Risks to patients were assessed however children who had safeguarding issues were not always highlighted on the practice computer system and the practice did not have a policy for safeguarding adults. However after our conversations with staff we were satisfied that they knew what action to take should they have any concerns with regards to the safeguarding of adults and children.
• 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. However a risk assessment for legionella had not been carried out. Legionella is a bacterium which can contaminate water systems in buildings. A legionella risk assessment is a report by a competent person giving details as to how to reduce the risk of the legionella bacterium spreading through water and other systems in the practice.
• 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.

• However there were areas of practice where the provider needs to make improvements.

  Importantly the provider must;

  Ensure that a risk assessment for legionella is carried out

  Importantly the provider should

• Ensure that there is a policy devised for the safeguarding of adults and that all children at risk of safeguarding incidents are flagged on the practice computer system.
• Ensure that learning from significant events is shared with all relevant members of staff to facilitate improvements and thus high quality patient care.

• Professor Steve Field CBE FRCP FFPH FRCGP

  Chief Inspector of General Practice