Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr AK Abeyewardene on 27 November 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. They were analysed and areas for improvement identified and cascaded informally to staff working at the practice.
- All staff had received safeguarding training and understood the various types of abuse that could take place.
- Medicines alerts were being acted upon but there was a lack of an audit trail to reflect that appropriate action had been taken.
- The practice had a recruitment process but pre-employment checks were not consistently undertaken. Staff were suitably qualified and experienced and received an induction when first starting at the practice.
- Patients on high risk medicines were subject to regular review and monitoring.
- Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
- Staff were aware of relevant legislation in relation to consent including the Mental Capacity Act 2005.
- Clinical performance was monitored regularly and performance against targets was above national and local averages and had been consistently maintained over the last two years. All staff understood their roles and were involved in achieving healthcare objectives.
- Data available to us, feedback on CQC comment cards and information received from the patients we spoke with reflected that patients were satisfied with the services provided.
- The practice had a clear vision and had identified the objectives of the practice. This was not being discussed with staff.
- There was visible leadership and staff felt included and valued.
However there were areas where the provider must make improvements;
- Ensure an there are records to reflect that action has been taken in relation to medicines alerts.
- Ensure appropriate recruitment checks are consistently undertaken for all new members of staff in line with legislation and that regular checks are made to ensure clinical staff are registered with their professional body.
- Undertake health and safety and legionella risk assessments.
- Ensure that the system of monitoring the expiry dates of the first aid equipment is effective.
There were also areas where the provider should make improvements;
- Ensure cleaning checklists are in place and infection control audits are undertaken in line with guidance.
- Ensure the learning from complaints, significant events and safety issues are discussed with all staff and their views sought where relevant. Ensure that action taken as a result of identified improvements is recorded to provide an audit trail for completion.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice