Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The project Surgery on 15 August 2016. The overall rating for the practice was good. The full comprehensive report on the 15 August 2016 inspection can be found by selecting the ‘all reports’ link for The Project Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 14 July 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 15 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• 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 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.

At our previous inspection on 15 August 2016, we rated the practice as requires improvement for providing safe services.

The registered person failed to have systems and processes established and operated effectively to enable them to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity, specifically in relation to the safe storage and management of vaccines.

At this inspection we found that the practice had implemented systems to ensure patients safety and had provided evidence to prove this.

Consequently, the practice is now rated as good for providing safe services.

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 Project Surgery on 15 August 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.

• Risks to patients were generally assessed and well 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. However, we did find administrative staff had been given the responsibility of checking and recording fridge temperatures without this being underpinned by the necessary training.
• 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 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:

• Review and improve the systems and processes in place, specifically in relation to the safe storage and management of vaccines, to ensurethey are established and operate effectively and that they enable the assessment, monitoring and mitigation ofthe risks relating to the health, safety and welfare of service users and others.

• Establish a suitable system to ensure the monitoring and usage of blank prescription forms and pads.

• Consider and mitigate the risks to patient care that may arise due to the lack of clinical cover between the hours of 12pm and 3pm, in particular to ensure patients are informed about alternative available services.

• Ensure staff files contain copies of all records necessary to be kept in relation to persons employed in the carrying on of the regulated activity, specifically in relation to employment history and interview records.

The areas where the provider should make improvement are:

• Ensure staff receive such appropriate support andtraining as is necessary to enable them to carry out the duties they are employed to perform, specifically in relation to the safe storage and management of vaccines.

• Review the provision and location of the crash bag to ensure the items within it are safely stored and do not pose a risk to those using the premises.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice