Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 17 March 2016. We issued a requirement notice in relation to Safe Care and Treatment. The practice sent in an action plan informing us about what they would do to meet legal requirements in relation to the following;

• The practice had not ensured that all medical devices for use were within their expiry date.

• The practice had not undertaken a robust legionella risk assessment.

They told us these issues would be addressed by 31 may 2016 and provided us with evidence to show they had taken the action to address the concerns.

We undertook a desk top review on 7 October 2016 to make a judgement about whether their actions had addressed the requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for 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 Guildhall Surgery Clare on 17 March 2016. Overall the practice is rated as good.

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

• The appointment system was flexible and ensured that patients who requested to be seen on the same day were.

• The practice had good facilities including disabled access. There was a lift for those patients who could not manage the stairs.

• Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG).

• The practice proactively managed care plans for vulnerable patients and had effective management strategies for patients at the end of their life.

• The practice had a number of policies and procedures to govern activity; however, some were introduced within the last six months and had not been embedded into the practice culture.

• Systems to reduce risks to patient safety for example, infection control procedures, needed to be improved.

• There was a leadership structure; however, at times it was not always clear there was a cohesive approach that gave clarity to staff and would lead to improvements. Staff generally felt supported by the management.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

The areas where the provider must make improvements are:

• Ensure that a risk assessment for the testing of legionella is completed and any identified actions are taken.

• Ensure that all medical devices available for use are within the expiry dates.

In addition the provider should;

• Continue to embed processes for reporting, recording, acting on and monitoring incidents and complaints to ensure reflective and shared learning.
• Continue to embed formal governance arrangements including systems for assessing and monitoring risks to patients and staff health and wellbeing.
• Continue to embed policies and guidance to enable staff to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• Carry out clinical audits including re-audits to ensure improvements have been achieved.

• Continue to strengthen the leadership structure to give clarity to staff and to deliver all improvements.

• Monitor systems in place to ensure that the monitoring of fridge temperatures is robust.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice