The Leith Hill Practice, 168 The Street, Capel, Dorking.
The Leith Hill Practice in 168 The Street, Capel, Dorking is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 24th February 2017
The Leith Hill Practice is managed by The Leith Hill Practice.
Contact Details:
Address:
The Leith Hill Practice The Old Forge Surgery 168 The Street Capel Dorking RH5 5EN United Kingdom
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Leith Hill Practice on 21 April 2016. The overall rating for the practice was good. However, during this inspection we found breaches of legal requirements and the provider was rated as requires improvement under the safe domain. The full comprehensive report for the April 2016 inspection can be found by selecting the ‘all reports’ link for The Leith Hill Practice on our website at www.cqc.org.uk.
Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-
Ensuring that infection control audits were documented and completed in the required timeframes. Where needed action plans were created with dates for completion which were monitored.
Ensuring that security measures for controlled drugs were reviewed to include the secure storage of keys when the practice was closed.
This inspection was an announced focused inspection carried out on 01 February 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 21 April 2016. The focused inspection has determined that the provider was now meeting all requirements and is now rated as good under the safe domain This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Our key findings were as follows:
The practice’s infection control lead was the practice nurse. We saw evidence of their advanced training for infection control. Infection control audits were undertaken every six months and there had been a recent Infection control audits in May and December 2016. We saw that actions had been recorded to address any concerns found and these were regularly discussed at meetings. All staff had received training on infection control.
The practice had reviewed security measures in place for controlled drugs. We saw evidence that only authorised staff had access to controlled drugs and that keys to the controlled drugs cabinet were stored securely in a separate key safe.
In addition we saw evidence of:
The recording of minutes and actions from partner meetings held. These were then disseminated to staff not present to support shared learning.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Leith Hill Practice on 21 April 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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.
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
Risks to patients were assessed and well managed with the exception of those relating to infection prevention and control. The practice had not documented regular infection control audits and therefore could not evidence the frequency of audits taking place as required by guidance. (Code of practice on the prevention and control of infections and related guidance issued by the Department of Health).
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 there was continuity of care, with urgent appointments 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:
Ensure that infection control audits are documented and completed in the required timeframes. Where needed action plans created with dates for completion which are monitored.
Ensure that security measures for controlled drugs are reviewed to include the secure storage of keys when the practice is closed.
In addition the provider should:
Review the recruitment information retained for locums.
Review the recording of minutes or actions from partner meetings held so as to ensure the dissemination of information to staff not present and to support evidence of shared learning.
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