Kingsfold Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingsfold Medical Centre on 12 September 2016. The overall rating for the practice was good with the key question of safe rated as requires improvement. The full comprehensive report on the September 2016 inspection can be found by on our website at http://www.cqc.org.uk/location/1-538845510

This inspection was a desk-based review carried out on 16 March 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 12 September 2016. This report covers our findings in relation to those requirements.

Overall the practice is now rated as good.

Our key findings were as follows:

• At the inspection in September 2016 we found that appropriate checks through the Disclosure and Barring Service (DBS) were not always carried out for some staff. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). The recruitment policy did not include the importance of undertaking a DBS check and required updating. At this desk-based review we saw evidence that the practice had carried out all necessary DBS checks and had revised the recruitment policy to include DBS checks for staff.
• At our previous inspection, we identified that the surgery did not review actions taken as a result of significant events in the practice. For this inspection, the practice provided evidence to show that a new significant event protocol had been developed and adopted by the practice in order to address this.
• At our inspection in September 2016, we found that although an infection control audit had been undertaken by the practice, there was no action plan to address the findings of the audit. At this desk-based review, we saw that a further audit had taken place, an action plan had been recorded and that work was underway to address those areas identified by the audit.
• At our previous inspection, we found that not all clinical staff had the necessary I.T. skills needed to access the practice policies and procedures. For this review, the practice provided evidence in the form of a staff signature sheet that showed that all staff were able to access the practice policies and procedures.
• During the inspection in September 2016, we noted that there was no information easily available to patients in the waiting area regarding the use of chaperones or information about the practice complaints procedure. For this inspection, the practice sent us a chaperone poster and a complaints poster which they told us were now displayed in the patient waiting area. The practice also supplied a patient complaints leaflet which was available in the reception area.
• At our inspection in September, we found that there was no formal mechanism for sharing and reviewing safety alerts and monitoring that actions were carried out. At this inspection, the practice supplied us with a new protocol for the management of patient safety alerts which we were told the practice had adopted.
• At our previous inspection, we found that some equipment maintenance had not taken place following electrical safety testing. The practice sent us evidence of further equipment testing and calibration carried out in February 2017 and evidence of up to date electrical testing that showed all equipment was safe to use.
• At the inspection in September 2016 we found that the practice did not have paediatric defibrillator pads available for the resuscitation of children in an emergency. For this inspection, the practice sent us proof of purchase of these pads.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice