Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 13 October 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 12 Safe care and treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 19 Fit and proper persons employed.

We undertook this focused inspection on 17 May 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Tickhill and Colliery Medical Practice on our website at www.cqc.org.uk. 

Overall the practice is rated as Good. Specifically,following the focused inspection we found the practice to be good for providing safe and well-led services.

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

• Systems and processes were in place to keep people safe. For example, the practice implemented a procedure to check all emergency drugs monthly and to record those medicines disposed of due to expiry dates. Staff who acted as chaperones had received training for the role in January 2016. Disclosure and barring service (DBS) checks were also completed for all staff and an annual infection prevention and control audit had been completed on 31 December 2015. We saw evidence that action was taken to address any improvements identified as a result.

• We reviewed two personnel files for staff starting at the practice in June 2016. We found appropriate recruitment checks had been undertaken.

• A fire risk assessment had been completed following our comprehensive inspection in October 2015 and we saw evidence actions identified were completed. Fire alarms were tested weekly and a fire evacuation drill was completed on 15 October 2015. 
• The partners had reviewed the governance framework to support performance and deliver good quality patient care. We saw evidence that all of the clinical and non-clinical policies and procedures had been reviewed and were available to all staff via their desktop on the practice computer.
• The practice had established a programme of internal audit to monitor quality and to make improvements. We were shown the planned audit schedule for the next 12 months.

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 Tickhill and Colliery Medical Practice on 13 October 2015. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Some risks to patients were assessed and managed, with the exception of those relating to recruitment checks, legionella risk assessment, fire equipment checks and infection prevention and control.
• Quality and Outcomes Framework(QOF) data showed patient outcomes were average for the locality. Some audits had been carried out and we saw some evidence audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Urgent appointments were usually available on the day they were requested. However patients told us they sometimes had to ring several times for non-urgent appointments as they were often not available to book in advance.
• The practice had a number of policies and procedures to govern activity, but some were over three years old and were past the review dates of 2013 and 2014. The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings.

The areas where the provider must make improvements are:

• Ensure the actions identified in the infection prevention and control audit are implemented in accordance with the findings.
• Ensure the proper and safe management of medicines.
• Ensure the fire extinguisher risk assessment actions are followed up and equipment tested regularly.
• The practice must take immediate action to ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. Specifically, this includes completing Disclosure and Barring Service (DBS) checks for those staff that need them.

In addition the provider should:

• Review arrangements for documenting actions taken as a result of best practice guidance and patient safety alerts.
• All staff must have access to appropriate up to date policies, procedures and guidance in order to carry out their role.
• Develop a locum GP information pack.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice