Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Emond, Copsey and Bailoor on 17 February 2016. Overall the practice was rated as good but required improvement for providing safe services.

During our last inspection we found the provider had not ensured that all risks to patients were assessed and managed. This included identifying and managing risks to the health and safety of patients and staff. The provider was asked to remedy these and a requirement notice for these improvements was issued.

Following the inspection an action plan was put in place by the practice to ensure the timely progression and resolution of the concerns highlighted.

On 30 September 2016 we conducted a desk top review and found;

• A fire and health and safety risk assessment of the service had been conducted on 25 April 2016. Consequently a number of action points had been identified, prioritised and were being actively progressed.
• The practice had conducted a risk assessment in relation to the control of substances hazardous to health (COSHH) such as cleaning materials.
• The fire assessment had been conducted in March 2016. Nominated staff had been appointed as fire wardens and supported to undertake additional training in the safe and effective use of the fire safety equipment.
• A legionella risk assessment had been conducted including water testing in March 2016.
• All clinical staff had been invited and received their Hepatitis B vaccinations to protect them from blood borne infections.
• Expired needles, syringes and blood collection bottles had been removed from GP consulting rooms and systems introduced to check and replace supplies.

We were satisfied that the practice had made the required improvements.

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 Drs Emond, Copsey and Bailoor on 17 February 2016. Overall the practice is rated as requires good. The practice is rated as requires improvement for safe and good for effective, caring, responsive and well led domains.

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

• The practice ensured that when things went wrong that these were investigated and learning was shared with staff.
• There were systems for assessing risks including those associated with medicines, equipment and infection control. However risk assessments had not been carried out for health and safety, the risk of fire and legionella. Staff who handled blood products and who were at increased risk of needle stick injury did not have up to date hepatitis immunity or vaccinations.

• We found some out of date needles, syringes and blood specimen bottles in GPs rooms and there were no systems in place for checking these.

• There was a detailed business continuity plan to deal with untoward incidents that may affect the day to day running of the practice.
• Staff were recruited with all of the appropriate employment checks having been carried out to determine each person’s suitability and fitness to work at the practice.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Clinical audits and reviews were carried out to monitor and improve patient care and treatment.

• Staff were supported and received role specific training to meet the needs of patients.
• Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment. They said that staff were helpful, polite and courteous.
• Information about services and how to complain was available and easy to understand. Complaints were investigated and responded to promptly and apologies given to patients when things went wrong or their experienced poor care or services.
• The practice offered a range of appointments including face to face, telephone and online consultations. Routine appointments could be booked in advance. Same day appointments were available.
• Patients said they found it easy to get through to the practice by telephone and to make an appointment with a named GP. They said that they usually got an appointment with their named GP within one week and that they could always get a same day emergency appointment if needed.
• The practice was accessible to patients with mobility difficulties and 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.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure that risks to patients and staff are assessed and managed. This includes identifying and managing risks to the health and safety of patients and staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice