Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 16 February 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of regulation 12(1) (2) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 10 October 2016 to check that the practice had followed their plan 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 Cheam Family Practice 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:

• Risks to patients were assessed and well-managed, including those related to recruitment checks, monitoring of vaccines stored on the refrigerators, monitoring of cleaning of the premises and fire safety.

There were areas of the practice where the provider should make improvements:

• Improve the practice systems for managing, monitoring and improving outcomes for diabetic patients.
• Improve recording of minutes for multidisciplinary team meetings to ensure patients are monitored effectively.
• Consider improving accessibility in the patient toilet at the Gander Green Lane site for patients with restricted mobility.

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 Cheam Family Practice visiting both the practice and branch site on 16 February 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.
•  Most risks to patients were assessed and well managed with the exception of thorough recruitment checks.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients were very satisfied with the level of service received. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services 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 adequate 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 improvements are:

• Ensure that appropriate recruitment checks are undertaken and recorded prior to employment for all staff.

In addition the provider should:

• Improve systems for management and monitoring of risks, specifically those associated with medicines stored in the refrigerators at both practice sites, those for monitoring cleaning at both sites and systems for regular fire drills and evacuation at the branch practice.
•  Improve the practice systems for managing, monitoring and improving outcomes for diabetic patients.
• Improve recording of minutes for multidisciplinary team meetings to ensure patients are monitored effectively.
•  Improve the information available in patient waiting areas for carers and about the complaints process.
• Ensure that lessons learnt and actions from complaints are clearly documented and cascaded to relevant staff.
•  Consider improving accessibility in the patient toilet at the Gander Green Lane site for patients with restricted mobility.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice