Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Broadway Surgery on 8 June 2016. The overall rating for the practice was good, however the practice was rated requires improvement for the safe key question. The full comprehensive report on the 8 June 2016 can be found by selecting the ‘all reports’ link for The Broadway Surgery on our website at www.cqc.org.uk.

At the inspection on 8 June 2016 we found there were concerns about safety systems and processes in respect of background checks for staff, infection control, medicines management, fire safety and arrangements to deal with emergencies and major incidents.

These arrangements had significantly improved when we undertook a follow up inspection on 4 September 2017.

This inspection was an announced focused inspection carried out on 4 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 8 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good.

Our key findings were as follows:

• Risks to patients were assessed and well managed. This included those relating to fire safety and staffing. 

• All staff undertaking chaperoning had undergone a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

• All staff had undergone infection control training. Funding and plans were in place to replace the carpets and chairs with those of a more suitable type for a clinical environment.

• An increased number of urgent appointments were made available. The provider had taken action to respond to patient’s experiences concerning difficulty getting appointments.

• The arrangements for managing medicines, including emergency medicines and vaccines, in the practice kept patients safe.

• There were suitable arrangements to deal with emergencies and major incidents.

At the inspection on 8 June 2016 we said the practice should:

• Review the telephone and booking system to ensure that patients are able to book appointments when needed and review the practice’s opening hours in light of patient feedback in the GP patient survey.

• Implement processes to improve their immunisation rates for five year olds.

• Ensure patients with caring responsibilities are proactively identified.

At the inspection on 4 September 2017 we found:

• The practice had reviewed and adjusted its opening time on Mondays and Fridays so that on those days it opened at 8am, rather than 9.30am. It also now closed at 7.30pm on Fridays, rather than 6.30. The two partners were also doing an additional session on those days in order to increase appointment availability. In addition pre-bookable appointments (48 hours in advance) were now available in the mornings whereas previously they were only available in the afternoons.

• Immunisation rates for five year olds had improved from 54% to 64% to 72% to 88%. Policies and procedures we in place to ensure control and oversight over performance in childhood immunisations.

• Patients who were also carers were being identified, however it was unclear how effective the processes and procedures in place were. We saw notices on display in the waiting area. The new patient registration form was amended to include a question about whether or not the patient was a carer. At the inspection on 8 June 2016 the practice had identified 12 patients as carers (0.2% of the practice list). At this inspection we found 34 patients had been identified (0.3%).

The areas where the provider should make improvement are:

• Take further steps to ensure the practice is able to respond appropriately in the event of an emergency by ensuring fire alarm checks are recorded and child pads for the defibrillator are obtained.

• Continue to review and improve processes and procedures for the identification of patients who are carers to ensure they receive the necessary level of care and support.

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 the Broadway Surgery on 8 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Some risks to patients were assessed and managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it difficult to make an appointment on occasions and urgent appointments were not always 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• The practice should ensure an automated external defibrillator (used to attempt to restart a person’s heart in an emergency) is available or should carry out a risk assessment to identify what action would be taken in an emergency.
• Ensure that staff who carry out chaperone duties are Disclosure and Barring Service (DBS) checked. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

The areas where the provider should make improvement are:

• Review the telephone and booking system to ensure that patients are able to book appointments when needed and rreview the practice’s opening hours in light of patient feedback in the GP patient survey
• Ensure the infection control lead undertakes further training to enable them to understand their role and provide advice on the practice infection control policy.
• Replace the carpets in the GP treatment rooms with washable surfaces, in line with infection control guidance.
• Ensure that all medication is correctly labelled and carry out regular medication checks to ensure they are stored appropriately.
• Install a fire alarm in line with health and safety regulations or carry out a risk assessment to show how staff would able to provide a warning to patients in the event of a fire
• Ensure that appropriate employment checks are carried out for all staff before they are employed.
• Implement processes to improve their Immunisation rates for five year olds.
• Ensure patients with caring responsibilities are proactively identified.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice