We carried out an announced comprehensive inspection of The Gardens Surgery on 25 November 2015 where the practice was rated good overall. However breaches of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified, and we rated the practice to require improvement for providing safe services.

The specific concerns in the previous inspection related to safety were:

• Not all staff had received the appropriate level of safeguarding or basic life support training.

• Not all staff who acted as chaperones had received a Disclosure and Barring Service check prior to being designated a chaperone.

• The practice was not conducting fire drills on a regular basis.

• Prescriptions kept in printers were not always appropriately stored and secured when clinical rooms were vacant.

• Children’s oxygen masks were not stored with the practice’s supply of oxygen which would have hindered their ability to respond effectively in an emergency.

• Some staff were not aware of the practice’s business continuity arrangements and there was no member of staff who had overall responsibility for disaster recovery.

In addition to this we found that some staff members had not been appraised within the previous 12 months.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 17(1).

We undertook this focussed inspection on 5 August 2016 to check that they had followed the action plan provided and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Gardens Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

• All staff had completed basic life support and safeguarding training within the last 12 months.

• All staff had received the requisite level of chaperoning training and background checks.

• The practice had carried out a fire drill where action points were learned from and implemented.

• The practice had implemented systems and processes to ensure that prescriptions held in printers were stored securely.

• The practice had stored the oxygen masks with the practice’s oxygen supply.

• The practice had made improvements to its business continuity arrangements. There were now packs with emergency supplies which could be used if the premises were not in operation and there was a designated person who was responsible for overseeing and making any required changes to the practice’s business continuity arrangements.

In addition to addressing the breaches of regulation which impacted on safety, the practice had taken additional action on the basis of our last report:

• The practice was in the process of giving reception staff customer service training and most staff appeared to have completed this.

• All staff had been appraised.

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

We carried out an announced comprehensive inspection of The Gardens Surgery on 25 November 2015 where the practice was rated good overall. However breaches of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified, and we rated the practice to require improvement for providing safe services.

The specific concerns in the previous inspection related to safety were:

• Not all staff had received the appropriate level of safeguarding or basic life support training.

• Not all staff who acted as chaperones had received a Disclosure and Barring Service check prior to being designated a chaperone.

• The practice was not conducting fire drills on a regular basis.

• Prescriptions kept in printers were not always appropriately stored and secured when clinical rooms were vacant.

• Children’s oxygen masks were not stored with the practice’s supply of oxygen which would have hindered their ability to respond effectively in an emergency.

• Some staff were not aware of the practice’s business continuity arrangements and there was no member of staff who had overall responsibility for disaster recovery.

In addition to this we found that some staff members had not been appraised within the previous 12 months.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 17(1).

We undertook this focussed inspection on 5 August 2016 to check that they had followed the action plan provided and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Gardens Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

• All staff had completed basic life support and safeguarding training within the last 12 months.

• All staff had received the requisite level of chaperoning training and background checks.

• The practice had carried out a fire drill where action points were learned from and implemented.

• The practice had implemented systems and processes to ensure that prescriptions held in printers were stored securely.

• The practice had stored the oxygen masks with the practice’s oxygen supply.

• The practice had made improvements to its business continuity arrangements. There were now packs with emergency supplies which could be used if the premises were not in operation and there was a designated person who was responsible for overseeing and making any required changes to the practice’s business continuity arrangements.

In addition to addressing the breaches of regulation which impacted on safety, the practice had taken additional action on the basis of our last report:

• The practice was in the process of giving reception staff customer service training and most staff appeared to have completed this.

• All staff had been appraised.

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