Letter from the Chief Inspector of General Practice
We had previously carried out an announced comprehensive inspection at this practice on 28 September 2016 and found breaches of regulation and rated the practice as ‘Requires improvement’ in the safe and well-led key question. The practice was rated as ‘Requires improvement’ overall. The full comprehensive report on the 29 September inspection can be found by selecting the ‘all reports’ link for The Uppingham Surgery on our website at www.cqc.org.uk.
Specifically we found that;
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The practice did not have a clear or consistent system for reporting, recording and monitoring significant events, incidents and accidents.
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The systems and process to address the risks associated with fire and legionella were not implemented well enough to help ensure people were kept safe.
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There was no clear process in place to alert health care professionals that patients were being prescribed disease modifying drugs in secondary care.
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The provider had not have systems in place to ensure that staff were properly recruited.
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The practice had a governance framework in place which supported the delivery of the strategy and quality care. However, we found the systems and processes in place with regard to significant events, monitoring of risk and staff recruitment were not effective
This inspection was an announced focused inspection carried out on 9 May 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 29 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
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The practice is now rated as ‘Good’ in the safe and well-led key questions and ‘Good’ overall.
Our key findings were as follows:
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There were systems for recording, monitoring, acting, reviewing and learning from significant events.
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There were systems to assess and monitor the potential risk from fire and legionella.
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Systems had been improved to help ensure that patient notes were summarised in a timely manner.
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There was a clear process in place for the management of disease modifying drugs prescribed for patients in secondary care.
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Staff were recruited only after the necessary checks had been made.
In addition we found that:
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Blank prescription pads were managed in line with national guidance.
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Random spot checking of the cleaning efficacy at all four surgeries had been introduced.
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Meeting agenda across all staff groups were formalised and discussions recorded.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice