Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 12 May 2016. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

• Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.
• Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only 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 Grassendale Medical Centre on our website at www.cqc.org.uk

Our key findings were as follows:

• The practice had addressed the issues identified during the previous inspection. Disclosure and Barring Service (DBS) checks had been completed for all necessary staff.
• The practice had carried out health and safety risk assessments and completed actions identified.
• Monitoring systems had been improved to manage and mitigate safety risks.

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 Grassendale Medical Centre on 12 May 2016. Overall the practice is rated as good but requires improvement for providing safe services.

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

• The practice was clean and tidy. There were limited facilities for disabled patients. There were translation services available.

• Feedback from patients and surveys indicated patients were satisfied with the standard of care received. However, there were concerns raised regarding the amount of time it took to get a pre- bookable appointment. The practice was aware of this. There had been changes in the practice due to retirement of GPs and the employment of salaried GPs. The practice was in the process of recruiting another GP.

• There were systems in place to mitigate some safety risks including analysing significant events and safeguarding.

• The practice did not follow some health and safety legislation to ensure the safety of both patients and staff. Some risk assessments for health and safety had not been carried out and when they had, some actions had not been undertaken for the risks identified such as fire safety. There were insufficient systems in place to oversee monitoring of safety aspects of the practice.

• Required pre- employment checks had not been carried out for all staff.

• Patients’ needs were assessed and care was planned and delivered in line with current legislation.

• Information about services was available. There was a virtual patient participation group (PPG).

However, there were areas where the provider must make improvements.

• Ensure appropriate recruitment checks are carried out for all their staff. For example, to have enhanced checks when staff act as chaperones.

• Complete health and safety risk assessments and any actions required as a result including continuous monitoring.

The provider should:

• Improve how they gain and act on patient feedback.

• Have a clear clinical management plan for nursing prescribers.

• Update policies to include named staff for lead roles.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with seven patients who used the service, including three members of the Patient Participation Group (PPG), during our inspection. A PPG is made up of a group of volunteer patients and practice staff who contact each other regularly to discuss the services on offer and how improvements can be made for the benefits of the local patient population and the practice. Everyone spoke positively about the practice and commented that they were happy with the care and treatment they had received. Some comments made were, “It is a very caring practice,” “The ethos of the practice is very good, they are a real family doctors” and “They are absolutely wonderful, I would recommend them to anyone.”

Patients were treated by staff that were appropriately trained and supported. The environment within the surgery was clean and tidy and the quality of the service provided was monitored on a regular basis.