We previously carried out an announced comprehensive inspection of Bailey Practice on 24 October 2018. At the inspection, we rated the practice as good overall, but as requires improvement for providing safe services because:

• The practice had not completed a risk assessment supporting the decision to allow a receptionist to work whilst their Disclosure and Barring Service (DBS) check was pending.
• There was no process to carry out regular fire alarms tests and the fire extinguishers had not been checked.
• There was no evidence that some medical equipment had been calibrated to ensure it was in good working order.
• The practice did not have an effective failsafe system to ensure that cytology test results were received and acted upon and was not auditing inadequate cervical screening rates.
• In relation to monitoring a particular high-risk medicine, some patient test results were not documented within patients’ notes before prescribing.
• The practice had a system for recording receipt and acknowledgement of safety alerts. However, there was no documentation of what action was taken by the practice.

The full report of the October 2018 comprehensive inspection can be found by selecting the ‘all reports’ link for The Bailey Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection of The Bailey Practice on 12 March 2019 to check whether the practice was providing safe care.

We based our judgement of the quality of care at this service is on a combination of:

• what we found when we inspected;
• information from our ongoing monitoring of data about services; and
• information from the provider, patients, the public and other organisations.

At this focused inspection on 12 March 2019, we found that the provider had made improvements.

We have rated this practice as good overall.

We rated the practice as good for providing safe services because:

• Enhanced DBS checks had been completed for all non-clinical staff.
• Fire alarm tests were carried out and documented on a monthly basis and the fire extinguishers had been checked.
• Medical equipment had been calibrated and the practice had created an inventory of all equipment to monitor calibration due dates.
• The practice’s cytology failsafe log was updated and monitored on an ongoing basis and the practice was auditing inadequate cervical screening rates.
• A specific prescribing protocol for warfarin had been created and we saw patients’ test results were documented within patients’ notes on the clinical system.
• There was an effective system for safety alerts with any action taken by the practice documented.

We also found the practice had acted upon a suggested area of improvement from the previous inspection, relating to the identification of carers:

• The practice had been proactive in identifying patients who are carers, by sending letters to patients with chronic conditions, creating a new carer’s information board in the waiting area, and asking patients during consultations if they were cared for or had caring responsibilities.
• The practice provided information to carers about local support services and groups.
• At our previous inspection the practice had 18 patients coded on the clinical system as being carers; at this inspection, the practice had identified 55 patients as carers (1.4% of the practice population).
• Carers were offered annual influenza vaccines and 34 of 55 patients (62%) had received an influenza vaccination in the current programme.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bailey Practice on 13 October 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led 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
• 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.
• 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 where the provider should make improvements. Importantly, the provider should:

• Ensure all staff receive updated training in infection control.
• Ensure the practice implements a system compliant with NHS Security of Prescription Forms guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Bailey Practice on 24 October 2018 as part of our inspection programme.

At the inspection we found:

• The practice had not completed a risk assessment supporting the decision to allow a receptionist to work whilst their Disclosure and Barring Service (DBS) check was pending.
• There was no process to carry out regular fire alarms tests and the fire extinguishers had not been checked.
• There was no evidence that some medical equipment had been calibrated to ensure it was in good working order.
• The practice did not have an effective failsafe system to ensure that cytology test results were received and acted upon and was not auditing inadequate smear rates.
• In relation to monitoring a particular high-risk medicine, some patient test results were not documented within the patient’s notes before prescribing.
• The practice had a system for recording receipt and acknowledgement of safety alerts. However, there was no documentation of what action was taken by the practice.
• There were adequate systems for reviewing and investigating when things went wrong. The practice handled complaints and significant events appropriately and was aware of the duty of candour.
• The practice reviewed and monitored the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to relevant and current evidence based guidance and standards.
• Patient feedback about the practice was extremely positive, with many patients commenting that it was the best GP practice they had attended.
• The practice’s GP patient survey results were above local and national averages for all questions.
• The practice had an active patient participation group who were involved with the development of the practice.
• The practice organised and delivered services to meet patients’ needs.
• There was a clear leadership structure, and staff told us that they felt able to raise concerns and were confident that these would be addressed.
• There was a focus on continuous learning and improvement.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

You can see full details of the regulations not being met at the end of this report.

The areas where the provider should make improvements are:

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and evidence t

able for further information.