Letter from the Chief Inspector of General Practice

The practice was rated good overall and is now rated good for providing safe services.

We carried out an announced comprehensive inspection of this practice on 27 May 2015. Breaches of legal requirements were found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a desk based focused inspection on 13 May 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. (A desk based focused inspection means the provider was able to send us evidence of the action taken to address the issues previously found rather than visiting the practice).

During our previous inspection on 27 May 2015 we found the following areas where the practice must improve:-

• Ensure that a legionella inspection is carried out.

• Ensure that all clinical staff have been checked with the Disclosure and Barring Service (DBS) prior to them commencing in post.

Our previous report also highlighted areas where the practice should improve:-

• Ensure that meeting minutes include details of which staff were present and a summary of discussions held to include actions to be taken and by whom.

• Support the patient participation group (PPG) to gather and review patient feedback on the practice and ensure this is recorded so that the practice demonstrates on-going learning from patient feedback and involvement.

• Ensure that identified health and safety risks are recorded in a way that details the actions to be taken to eliminate or reduce the risk of harm.

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

During this inspection we found:

• The practice had conducted a legionella inspection and completed the necessary works to ensure safety.

• All clinical staff had received a criminal record check via the DBS and the practice had a policy to ensure that new clinical staff received a DBS check prior to them commencing in post.

We also found in relation to the areas where the practice should improve:

• That the practice was able to provide evidence that meeting minutes included details of which staff were present and a summary of discussions held which included actions taken.

• The practice was able to provide evidence that they had supported the PPG to gather and review patient feedback on the practice and that this information was recorded and published on the practice website.

• The practice was able to demonstrate that identified health and safety risks were recorded in a way that detailed the actions to be taken to eliminate or reduce the risk of harm.

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 Pavilion Surgery on 27 May 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, caring, effective and responsive services. It was also good for providing services for the care of 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 with the exception of those relating to legionella re-inspection and ensuring all clinical staff had received DBS checks prior to commencing in post.
• The process of risk assessment was focused on the identification and monitoring of risk, however a documentation did not clearly record control measures or summaries of action taken.
• 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 and planned.
• 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.
• 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.
• 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 legionella inspection is carried out.
• Ensure that all clinical staff have received a DBS check prior to them commencing in post.

In addition the provider should;

• Ensure that meeting minutes include details of which staff were present and a summary of discussions held to include actions to be taken and by whom.
• Support the PPG to gather and review patient feedback on the practice and ensure this is recorded so that the practice demonstrates on-going learning from patient feedback and involvement.
• Ensure that identified health and safety risks are recorded in a way that details the actions to be taken to eliminate or reduce the risk of harm.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This announced inspection was to follow up on the shortfalls identified during our inspection completed in October 2013.

Shortfalls had been identified in: care and welfare of people, safeguarding people from abuse, cleanliness and infection control and requirements relating to workers.

Following our inspection completed in October 2013, Pavilion Surgery provided us with an action plan detailing how they would address the shortfalls and stated they would be compliant in all areas by February 2014.

This inspection found Pavilion Surgery made certain the treatment people received was planned and delivered in a way that was intended to ensure patients safety and welfare. We found patients who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Pavilion Surgery ensured patients were fully protected from the risk of infection because appropriate guidance had been followed and patients were cared for by properly qualified staff.

We used a number of different methods to help us understand the experiences of people who used the service. We observed interaction between staff and people. We reviewed records and systems and looked at the environment and how this impacted on the service delivery. We spoke with seven people who used the service. We spoke with staff that included; the practice manager, a practice nurse, two healthcare assistants, a receptionist, a receptionist/secretary and two GP’s in the partnership.

This told us that the majority of people had been able to get an appointment when they needed one. Their care needs had been assessed; they had time to discuss their health care issues, and had been fully involved in making decisions about their care and treatment. Comments received included ”They are so professional,” and “ I have always been treated very well at this practice.” However, systems were not demonstrated to be in place to ensure all the emergency equipment and drugs were available for use when needed.

Policies and procedures were in place to protect vulnerable adults and children. However, not all the staff in the practice had received training to ensure they had an understanding of what constituted abuse appropriate to their role.

People told us the practice was always clean. They could remember that clinical staff had washed their hands before examining them or carrying out a procedure. However, systems were not found to be in place that ensured all infection control procedures in the practice met current requirements.

Recruitment policies and procedures in place did not protect people who used the service.

The practice had procedures in place to review the quality of the service provided. These processes had ensured information provided was used to improve the service.