We carried out an announced comprehensive inspection at West Barnes Surgery on 19 October 2017. The overall rating for the practice was Good, but the practice was rated as Requires Improvement in the safe domain. The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for West Barnes Surgery on our website at www.cqc.org.uk.

Following the October 2017 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), 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this announced focussed inspection on 15 June 2018 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements.

Overall, the practice remains rated as Good, and is now rated as Good for the Safe domain.

Our key findings were as follows:

• During the previous inspection in October 2017, we found that the practice had failed to address some risks identified in their fire risk assessment. When we returned to the practice in June 2018 we found that all identified risks had been addressed.
• During the previous inspection, we found that the practice was unable to provide evidence to show that they had considered, and put plans in place to mitigate, some risks identified in their infection prevention and control (IPC) risk assessment. When we returned to the practice in June 2018 we saw evidence that a log of actions to address IPC risks was being kept, and that regular internal IPC audits were being conducted.
• During the previous inspection in October 2017 the practice was unable to demonstrate how they ensured that staff were aware of their responsibilities in respect of IPC. When we returned to the practice in June 2018 we found that staff were receiving regular IPC updates from the IPC lead and that all staff had attended formal IPC training.
• During the previous inspection in October 2017 we found that the practice had not implemented the regular water testing recommended following their Legionella risk assessment. When we returned to the practice in June 2018 we found that two of the three monthly water monitoring tests were being carried-out; however, one of the tests recommended had been overlooked.
• During the inspection in June 2018 we found that the practice had not considered the risks relating to the storage of liquid nitrogen.
• During the previous inspection in October 2017 we found evidence of patient test results which were awaiting review by a GP who was not scheduled to attend the practice until the following week. When we returned to the practice in June 2018 we saw evidence that a buddy system was in place amongst GPs to ensure that all test results were reviewed in a timely way during staff absence.

The areas where the provider should make improvements are:

• Complete all regular testing of their water system recommended by their Legionella risk assessment.

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 West Barnes Surgery on 19 October 2017. Overall the practice is rated as good, however we found the provision of safe services required improvement.

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

• The practice systems and processes to minimise risks to patient safety were not effective with regards to infection prevention and control, health and safety, and fire safety.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Data from the quality and outcomes framework (QoF) showed that patient outcomes in the practice were consistently high, demonstrating good quality care.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

• Assess the risks to the health and safety of service users receiving care and treatment, including the risk of infections, and ensure the premises used by the service are safe to use for their intended purpose.

The areas where the provider should make improvement are:

• Review the systems in place to check patient test results to ensure urgent test results are always seen and actioned in a timely way.
• Review how patients with hearing difficulties and other impairments are communicated with.

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 West Barnes Surgery on 26 May 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was good at providing services for all the population groups including older people; people with long term conditions; mothers, babies, children and young people; the working age populations and those recently retired; people in vulnerable circumstances and people experiencing poor mental health.

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.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• 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.
• 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.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with three people using the service on the day of our inspection. People were mostly positive about their experiences of using the service. One person said, “It’s very good here. I always get an appointment when I need one and the care is really good.” Another told us they had no issues or concerns about the care and treatment they had received at the practice. Another said GP’s were attentive but they sometimes found it difficult to book a non-urgent appointment to see a GP or a Practice Nurse.

During our inspection we also spoke with one of the registered managers, who was also a practice GP, the practice manager and to a member of the patient participation group (PPG). We also met with the assistant practice manager, the practice nurse and reception staff.

People told us practice staff involved them in discussions about their care and treatment. People said staff explained things to them in a way they were able to understand. From the records we looked at we saw practice staff gave people appropriate information and involved them in discussions about their care and treatment options.

The practice had procedures in place for staff to report any concerns they had about the welfare and wellbeing of people and children using the service. Practice staff had received training and information about how to protect children and vulnerable adults if they suspected they were at risk of abuse, harm or neglect.

People told us the environment was clean and tidy. From our own observations the practice was clean and had been well maintained. There were appropriate policies and procedures in place to prevent and control the risks of cross infection.

People were asked for their views and experiences about using the service and this had been used to make changes and improvements that people wanted. Practice staff undertook regular audits to monitor and review the quality and safety of the care and treatment provided to people using the service. Learning from these audits had been used to make improvements and changes within the practice.