Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Station Road Surgery on 1 December 2015. The practice had been rated as good for effective, caring, responsive and well-led, however, required improvement in safe. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensure that all staff have completed relevant training for fire safety, infection control and information governance in line with the practice training requirements.
• Complete a legionella risk assessment.
• Carry out regular fire drills.

We undertook this announced focused inspection on 15 August 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and are rated as good under the safe domain.

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

• Staff had received training as required by the practice.
• A legionella risk assessment had taken place in December 2015 and no concerns had been found.
• A full fire drill with staff and patients had been completed in December 2015 and staff were aware of the procedures to follow in case of an evacuation.

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 Station Road Surgery on 1 December 2015. The practice had been rated as good for effective, caring, responsive and well-led, however, required improvement in safe. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensure that all staff have completed relevant training for fire safety, infection control and information governance in line with the practice training requirements.
• Complete a legionella risk assessment.
• Carry out regular fire drills.

We undertook this announced focused inspection on 15 August 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and are rated as good under the safe domain.

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

• Staff had received training as required by the practice.
• A legionella risk assessment had taken place in December 2015 and no concerns had been found.
• A full fire drill with staff and patients had been completed in December 2015 and staff were aware of the procedures to follow in case of an evacuation.

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

On the 4 February 2014 we found the provider non-compliant in the regulation for the requirements for workers. The provider sent us a report that set out the steps they would take to ensure they met the regulations. At this inspection we found the provider had taken all necessary steps and was now compliant with the regulations.

We spoke with the practice manager who explained the process they would undertake to ensure relevant information was obtained for new employees. This included a full works history with any gaps explained, conduct and reasons for leaving explored with past employers where the person had worked with children, vulnerable adults or in a health and social care setting. The practice manager told us they would also check if staff were physically and mentally fit to carry out their role and where required proof of registration with a professional body.

The practice recruitment policy was up to date and reflected information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Staff recruitment files we reviewed contained relevant information. This included photographic identification checks, a health declaration signed by the employee and a Disclosure and Barring Service (DBS) check. The DBS enables organisations to make safer recruitment decisions by identifying candidates who may be unsuitable for certain work.

We did not speak to patients during this inspection.

People told us that they were happy with the standard of care and treatment provided at Station Road Surgery. One person commented, ‘The overall service I have received at this practice from doctors, nurses and receptionists is, and always has been excellent’.

We saw evidence of good and regular interaction with other health care providers and noted that the service had entered into a ‘Shared Care protocol’ with a view to providing co-ordinated care to people. This enabled local health care providers to share information on the basis that ‘Better information means better care’. We noted that people had the right to opt out of this process, though none had done so.

In general, people who used the service told us they felt safe and had confidence in the staff to protect them from abuse. One person wrote, ‘I have never felt unsafe here and find the doctors and nurses to be very professional’. We found that staff had been trained and were aware of their safeguarding obligations.

We reviewed the practice arrangements in relation to the ordering, storage, administration and disposal of medicines. We found in general that procedures were safe and robust.

We found that the service had not adopted recruitment procedures introduced under relevant regulations, which were designed to confirm the suitability of employees. However, the provider had undertaken to do so as soon as possible.