Archived: Windermere Road Surgery

Letter from the Chief Inspector of General Practice

This is a focused follow-up inspection of Windermere Road Surgery for areas within the key question safe. We found the practice to be good in providing safe services. Overall the practice is rated as good.

The practice was previously inspected on 27 April 2017. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection the practice was rated good overall. However, within the key question safe, areas were identified as requiring improvement because the practice was not meeting requirements at that time.

• The provider did not carry out fire safety or infection control risk assessments.

• Where risk assessments had been carried out in 2015 in relation to fire safety, the provider had not actioned the risks identified.

• They had failed to identify the risks associated with the type of blinds fitted throughout the surgery which were not compliant with current regulations.

• The provider did not carry out full recruitment checks including full employment history and proof of identity for all staff.

The practice provided us with an action plan detailing how they were going to make the required improvements.

The full comprehensive report following the inspection on the 27 April 2017 is available on our website at www.cqc.org.uk/location/1-2309596339

The focused follow up inspection on 28 July 2017 was to confirm the required actions had been completed and award a new rating in the domain of safe, if appropriate.

On this inspection we reviewed a range of documents which demonstrated they were now meeting the requirements.

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 Windermere Road Surgery on 27 April 2017. 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 a system in place for reporting and recording significant events.
• The practice did not have a comprehensive, up to date annual infection control audit, although they did carry out a weekly walk round.
• The practice had last carried out a fire risk assessment in 2015 and had not actioned the identified risks.
• Although staff were aware of current evidence based guidance the practice did not have a system in place to ensure that new guidance had been adopted by the clinical team.
• Blinds at all windows in the surgery were not compliant with current regulations and were potentially hazardous due to them having a loop system in place.
• The practice did not have a system in place to ensure that alerts had been actioned by the practice.
• The practice did not always carry out pre employment recruitment checks.
• 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.
• Information about services and how to complain was available. 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 did not have a hearing loop but other facilities were good and the practice was well equipped to treat patients and meet their needs.
• The practice told us that parts of the practice were to be refurbished during the week after the inspection.
• 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:

• Carry out a comprehensive annual infection control audit to prevent the risk of health care associated infection.
• Fit all windows with blinds which meet current regulations
• Carry out regular fire risk assessments and action any risks identified.
• Carry out full recruitment checks before employing new members of staff.

The areas where the provider should make improvement are:

• Introduce systems to ensure that alerts and updates to current guidance were actioned and in place.
• Seek patient feedback regarding the purchase of a hearing loop, particularly those that would benefit from this.
• Keep a record of the immunisation status for all GPs and staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice