Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Grayshott Surgery on 1 March 2016. The practice had been rated as good for effective, caring and responsive. However, the practice required improvements in the safe and well led domains. After the comprehensive inspection in March, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following, the provider must:-

• Ensure that regular fire alarm checks are carried out and documented.
• Ensure that health and safety checks for the building and equipment are carried out and documented in line with practice policy.
• Investigate ways to re-establish a patient participation group to provide patient input to the practice.
• Review how learning is shared across the practice. For example from significant events and complaints. Ensure clear communication procedures are in place to ensure all relevant staff are aware of learning from events. Ensure a written record is kept of all verbal complaints so trends can be reviewed and analysed.
• Ensure that records are kept of all training completed by staff.

In addition the provider should:

• Review the training policy to show what training is required for each staff group and when refresher training is required.
• Ensure that recruitment reference checks and disclosure and barring service (DBS) checks are completed in line with practice policies. (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).
• Ensure that hand written prescription pads are kept secure at all times when taken off site, and that usage is monitored and recorded.

We undertook this announced focused inspection on 5 October 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. We found that the provider was now meeting all requirements and is rated as good under the safe and well led domains.

This report only covers our findings in relation to those requirements. We found:

• Fire alarms were now checked weekly and a full fire evacuation had taken place, with another planned for October 2016.
• A electrical installation condition check had been completed in June 2016 which showed no concerns. Non clinical electrical items had also been PAT (portable appliance test) tested and the practice had plans in place for this to be repeated every two years (clinical electrical equipment was tested yearly).
• A patient participation group (PPG) had been started and we saw evidence of meetings that had taken place. The PPG had produced a leaflet which contained information about the role of the PPG to try and help recruit other patients.
• Significant events and complaints were now routinely discussed during informal daily meetings and at monthly meetings with the GP’s and nurses. We saw evidence of shared learning and saw minutes of meetings where these were discussed. The practice also reviewed all significant events and complaints on a yearly basis to re-enforce any learning and look for any trends. Verbal complaints were also being recorded and were reviewed by the practice manager.
• A new training tracker on the practices computer system had been introduced. This allowed staff members to log on to their own profile and review the dates of their training. The practice manager was able to review all staff members accounts to ensure that required training had been completed and retained copies of their certificates.

In addition we saw evidence that the provider had:

• Introduced a new training tracker which enabled staff members to know when their mandatory training needed to be renewed.
• Ensured that recruitment checks included completing a risk assessment as to if a DBS check was required for individual roles and where required DBS checks had been completed.
• Reviewed prescription pad monitoring and had a system in place to track prescriptions pads when taken off site. Pads were kept secure at all times.

This report should be read in conjunction with the last report from 1 March 2016. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

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 Grayshott Surgery on 1 March 2016. The practice had been rated as good for effective, caring and responsive. However, the practice required improvements in the safe and well led domains. After the comprehensive inspection in March, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following, the provider must:-

• Ensure that regular fire alarm checks are carried out and documented.
• Ensure that health and safety checks for the building and equipment are carried out and documented in line with practice policy.
• Investigate ways to re-establish a patient participation group to provide patient input to the practice.
• Review how learning is shared across the practice. For example from significant events and complaints. Ensure clear communication procedures are in place to ensure all relevant staff are aware of learning from events. Ensure a written record is kept of all verbal complaints so trends can be reviewed and analysed.
• Ensure that records are kept of all training completed by staff.

In addition the provider should:

• Review the training policy to show what training is required for each staff group and when refresher training is required.
• Ensure that recruitment reference checks and disclosure and barring service (DBS) checks are completed in line with practice policies. (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).
• Ensure that hand written prescription pads are kept secure at all times when taken off site, and that usage is monitored and recorded.

We undertook this announced focused inspection on 5 October 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. We found that the provider was now meeting all requirements and is rated as good under the safe and well led domains.

This report only covers our findings in relation to those requirements. We found:

• Fire alarms were now checked weekly and a full fire evacuation had taken place, with another planned for October 2016.
• A electrical installation condition check had been completed in June 2016 which showed no concerns. Non clinical electrical items had also been PAT (portable appliance test) tested and the practice had plans in place for this to be repeated every two years (clinical electrical equipment was tested yearly).
• A patient participation group (PPG) had been started and we saw evidence of meetings that had taken place. The PPG had produced a leaflet which contained information about the role of the PPG to try and help recruit other patients.
• Significant events and complaints were now routinely discussed during informal daily meetings and at monthly meetings with the GP’s and nurses. We saw evidence of shared learning and saw minutes of meetings where these were discussed. The practice also reviewed all significant events and complaints on a yearly basis to re-enforce any learning and look for any trends. Verbal complaints were also being recorded and were reviewed by the practice manager.
• A new training tracker on the practices computer system had been introduced. This allowed staff members to log on to their own profile and review the dates of their training. The practice manager was able to review all staff members accounts to ensure that required training had been completed and retained copies of their certificates.

In addition we saw evidence that the provider had:

• Introduced a new training tracker which enabled staff members to know when their mandatory training needed to be renewed.
• Ensured that recruitment checks included completing a risk assessment as to if a DBS check was required for individual roles and where required DBS checks had been completed.
• Reviewed prescription pad monitoring and had a system in place to track prescriptions pads when taken off site. Pads were kept secure at all times.

This report should be read in conjunction with the last report from 1 March 2016. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This was a follow up inspection to check the provider had taken the required actions to meet essential standards following our previous inspection in February 2014.

During this inspection we spoke with the practice manager, assistant manager and the practice nurse responsible for infection control within the practice.

We found the provider had implemented processes to ensure people were protected from the risk of infection. People were cared for in a clean, hygienic environment.

Since our last inspection, the provider had taken steps to improve their recruitment processes. Appropriate checks were undertaken before staff began work. People were cared for and supported by suitably qualified, skilled and experienced staff. Personnel records had been updated to include evidence that staff had confirmed they were medically fit to carry out their duties.

We carried out this inspection to look at the care and welfare provided to patients by the staff of Grayshott Surgery. During our visit we spoke with three patients and five members of staff which included the registered manager. We also collected nine responses to a questionnaire we left in the waiting area.

We saw that staff treated patients with respect, for example we saw that staff closed doors of the consulting and treatment rooms which provided privacy and dignity to patients. All of the patients that we spoke with told us that they felt respected by the staff at the practice. One patient told us “I am always greeted politely.” Another patient said “In 30 years I have not once been treated disrespectfully.”

We found that the practice worked closely with a number of other healthcare professionals and services. Patients who had been referred outside of the practice told us that the process had been smooth and efficient.

We found the practice clean, tidy and well organised. However, we found some sterile items of equipment that had expired in several of the consulting rooms.

We looked at a sample of staff files and found that the provider had not ensured that they had carried out the necessary checks which related to staff recruitment.

We saw that the practice had a complaints policy which was made available to patients. We noted that complaints were responded to in a timely manner.

Patients seemed generally happy with Grayshott Surgery. We were told by one patient “100% praise for the doctors here.” Another said “Excellent service.”