Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Village Surgery on 25 November 2015. The overall rating for the practice was good but the practice required improvement for safety. The full comprehensive report for the 25 November 2015 inspection can be found by selecting the ‘all reports’ link for The Village Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 January 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 25 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Good.

Our key findings were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Records relating to investigations and meetings had been improved.

• Systems to monitor all appropriate action had been completed in relation  safety alerts had been improved.

• Recruitment processes had improved and appropriate recruitment checks had been undertaken as per the practices’ own policy and procedure.

• Systems had been implemented to record competency checks where these had been completed  to check members of staff level of skill in tasks relating to their role. An overview of staff training had been developed to enable staff training to be monitored.

• Risks relating to infection prevention and control had been assessed.

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 Village Surgery on 25 November 2015. 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 although some records relating to investigations and meetings should be more detailed.
• Appropriate recruitment checks had not always been undertaken as per the practices’ own policy and procedure.
• Risks to patient’s health and safety were assessed and well managed.
• 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 although evidence, for recently recruited staff, was not always available to support this.
• 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.
• 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:

• Appropriate recruitment checks had not always been undertaken as per the practices’ own policy and procedure. For example, two written references, checks of registration with the appropriate professional body, certificates of training and the appropriate checks through the Disclosure and Barring Service had not always been obtained.

The areas where the provider should make improvement are:

• There was a lack of detail in recording investigations of incidents, minutes of meetings where incidents had been discussed and actions undertaken.
• Medical alerts were not monitored to ensure all appropriate action had been completed.
• Competency checks had not been recorded where these had been carried out to check members of staff level of skill in tasks relating to their role. An overview of staff training was not maintained to enable staff training to be monitored.
• Risks relating to infection prevention and control had not been assessed.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice