Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Barretto & Partners, Thornton Heath Health Centre on 7 December 2016. The overall rating for the practice was good with requires improvement in Safe. Breaches of legal requirements were found relating to the Safe domain. The provider did not ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons were deployed: For example, not all staff had received appropriate training including fire safety, infection control and information governance. Also the provider did not have processes in place to ensure references were followed up.

After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report can be found by selecting the ‘all reports’ link for Dr Barretto & Partners, Thornton Heath Health Centre on our website at www.cqc.org.uk.

This inspection was a document-based review carried out on 8 September 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 7 December 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as Good for providing Safe services, and overall the practice remains rated as Good

Our key findings were as follows:

• The practice had reviewed its policy on obtaining references for new staff. We saw a revised policy, a reference and a completed induction checklist, as one new member of staff had been recruited since the last inspection.

• The practice had reviewed its policy on training; we saw a copy.

• All staff had completed role appropriate training including fire safety training, infection control and information governance; we saw certificates for all staff members to demonstrate this.

• Comprehensive meeting minutes were taken, detailing mandatory training including basic life support, safeguarding, information governance, infection control and when staff should have this training completed by.

• An updated business plan had been drafted which had been reviewed in March 2017, which included all staff contact details: we saw a copy of this.

• The practice had discussed their mission statement with all staff; we saw an agenda and meeting minutes of this discussion.

• We saw copies of the updated complaints policy and complaints leaflet.

• An updated recruitment selection and interview policy had been had been reviewed in January 2017, we saw a copy of this.

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 Dr Barretto & Partners, Thornton Heath Health Centre on 7 December 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 for reporting and recording significant events.
• Risks to patients were 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.
• 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 improvements are:

• Review recruitment procedures to ensure references are obtained before employing staff.

• Review training procedures to ensure all staff have role appropriate training including fire training, infection control and information governance.

The areas where the provider should make improvement are:

• Review the business continuity plan to ensure staff contact and buddy practice details are available.

• Review staff understanding of the practice mission statement.

• Review complaints procedures to ensure verbal complaints are recorded as well as written ones.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice