Letter from the Chief Inspector of General Practice

This is a focused desk based review of evidence supplied by North Shore Surgery to demonstrate what action they have taken to improve the service in the key question of Safe.

Overall, the practice is rated as good. Following this focused desk based review of the practice; we found the practice to be good in relation to providing Safe services.

North Shore Surgery was inspected on the 23 July 2015. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At that inspection, the GP practice was rated ‘good’ overall. However, we found the practice to require improvement for the domain or key question Safe. This was specifically in relation to recruitment procedures and the checks carried out to ensure the suitability of staff for their roles. This was because the practice was not meeting the requirements of Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Fit and proper persons employed.

We found there were significant gaps in the recruitment records of new staff. The practice did not maintain appropriate records to demonstrate that all newly recruited staff including some clinical staff had been appropriately vetted to ensure they were suitable and safe to work with potentially vulnerable adults and children.

The practice submitted an action plan with timescales detailing how they would ensure they met the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. They supplied us with evidence to confirm that all staff employed at the practice had been appropriately vetted, that disclosure and barring checks (DBS) were available for all staff, including locum GPs and the practice’s recruitment policy had been updated. In addition they supplied a copy of their updated recruitment policy.

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 North Shore Surgery 23 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for all the population groups. It required improvement for providing safe services.

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

• 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.

• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified. However, records of further planned training were not well developed.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand. However, patients we spoke with were not aware of the procedure.

• Patients said access and getting an appointment was usually satisfactory. Urgent appointments were available each day.

• The practice was located within in a modern multipurpose building with access to leisure facilities, community health care services and local government offices. The practice facilities were spacious, were accessible to patients with disabilities and were fully equipped to treat patients and meet their needs.

• 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.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure recruitment arrangements include all the required pre-employment checks for all staff.

In addition the provider should:

• Introduce a system to ensure that clinical audits are planned and structured so that the practice benefits form the outcomes of those undertaken.

• Ensure periodic analysis of complaints and patient feedback is carried out to identify themes and trends so that appropriate action can be taken if required.

• Ensure a staff training matrix is recorded so that staff training needs are monitored effectively and future training can be planned for more efficiently.

• Ensure a succession plan is developed and implemented to mitigate any risk to service delivery and quality in the event of a GP retiring.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about North Shore Surgery on 14 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.