Care Quality Commission

Letter from the Chief Inspector of General Practice

During an inspection looking at part of the service.

We carried out an announced comprehensive inspection at Southbourne Surgery on 22 March 2016. Overall the practice was rated as good for providing effective, caring and responsive services; and was rated as requires improvement for providing safe and well-led services. As a result, the practice was given an overall rating of requires improvement. Following the inspection we issued two requirement notices. A notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment; and a notice was issued due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to good governance.

There were several areas of risk identified at Southbourne Surgery. Within our last inspection report we said the provider must ensure that:

• Policies and procedures for infection control were fully implemented including a robust system for stock checks and appropriate use of sharps safes.
• A risk assessment was undertaken for all staff, such as administrators who did not have a Disclosure and Barring Service (DBS) check in place.
• All staff were trained to the appropriate level in adult and child safeguarding, and that there was evidence to confirm this.
• A system of annual staff appraisals was implemented.
• All equipment, including the stair lifts, had appropriate maintenance checks and was suitable for use.
• Staff were trained and were confident to support patients in the use of equipment such as the stair lift.
• A system was put in place so that policies and procedures were updated and implemented, and staff were aware of how to access them.

We undertook a focused inspection of the practice on 28 March 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 22 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings across all the areas we inspected during this inspection, were as follows:

• We saw documentary evidence of a system, which was now in place to check medical consumables expiry dates in all clinical rooms. All sharps safe expiry dates were checked and sharps safe pouches that were full or not used were disposed of after three months.
• We saw documentary evidence that Disclosure and Barring Service (DBS) checks were applied for or recorded in personnel files for existing staff employed prior to CQC registration, as well as new staff. We also saw documentary evidence that a risk assessment tool was in place to determine whether administrative staff required a DBS check.
• We saw documentary evidence that all staff were trained to the appropriate level in adult and child safeguarding.
• We saw documentary evidence that the practice had implemented a system of annual staff appraisals.
• We saw documentary evidence that the practice stair lifts had appropriate maintenance checks and were suitable for use.
• Staff demonstrated that they were fully trained and confident to support patients in the use of stair lift equipment.
• We saw documentary evidence that a system had been put in place to update and implement policies and procedures, and we spoke to staff who demonstrated awareness of how to access them.

Following this inspection the practice was rated as good overall across all domains.

Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice