Martins Oak Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Martins Oak Surgery on 13 January 2016. Breaches of legal requirements were found during that inspection within the safe and effective domains. The practice was rated as requires improvement overall, requires improvement in the safe and effective domains and good in the caring, responsive and well-led domains. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:

• Ensuring that the practice holds a child protection register of all children considered to be at risk.

• Ensuring that the practice has a clear adult safeguarding protocol in place and that all staff are aware of how to raise concerns outside of the practice.

• Ensuring that all staff attend relevant safeguarding training including reception and administrative staff and that all GPs have attended level three training in children’s safeguarding.

• Ensuring that the practice maintains a log of all staff training and that mandatory training requirements are met for all staff.

• Ensuring that environmental and legionella risk assessments are carried out and regularly reviewed.

• Ensuring that infection control procedures are clearly embedded and include regular annual infection control audits with action taken, the appointment of a dedicated infection control lead and infection control training for all staff.

• Ensuring that there is a system in place to monitor the use of prescription sheets stored in printers including ensuring they are locked away when not in use.

We undertook a focused inspection on 23 August 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as good overall and good under the safe and effective domains. This report only covers our findings in relation to those requirements.

This report should be read in conjunction with the last report from January 2016. Our key findings across the areas we inspected were as follows:

• The practice held a child protection register of all children considered to be at risk.

• The practice had an adult safeguarding protocol in place and staff were aware of how to raise concerns.

• All staff had undertaken both child and adult safeguarding training appropriate to their role within the stated timeframe. All GPs had attended level three training in child safeguarding.

• The practice maintained a comprehensive log of staff training requirements and staff had completed mandatory training such as safeguarding, basic life support and infection control.

• The practice had carried out environmental and legionella risk assessments and had identified review dates.

• The practice had a dedicated infection control lead. The audit had been repeated by the infection control lead and action had been taken on the findings. All staff had received appropriate training in infection control.

• The practice had a system to ensure the security of printer prescriptions when not in use and have put in place a new system to monitor the use of blank printer prescription sheets.

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 Martin’s Oak on 13 January 2015. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Some risks to patients were assessed and well managed, however not all environmental risk assessments had been carried out and the practice did not have a legionella risk assessment in place.
• Prescription pads were securely stored although there was no systems in place to monitor their use and prescription sheets stored in printers were not locked away when not in use.
• The practice had some safeguarding arrangements in place such as a children’s safeguarding protocol, a safeguarding lead and training for all clinical staff. However, not all administrative staff had attended safeguarding training, not all GPs had attended level 3 children’s safeguarding training, and there was no child protection register or adult safeguarding protocol in place.
• There were infection control procedures in place, however due to changes in staffing and infection control leads, systems were not always clearly embedded. For example we did not see regular annual infection control audits having been carried out and there was no system in place for regular infection control training for all staff by the infection control lead, including handwashing.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However, the practice did not maintain a training log of all staff training including GPs and mandatory training was not up to date for all staff. For example administrative staff had not attended training in infection control and safeguarding.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Ensure that the practice holds a child protection register of all children considered to be at risk.

• Ensure that the practice has a clear adult safeguarding protocol in place and that all staff are aware of how to raise concerns outside of the practice.

• Ensure that all staff attend relevant safeguarding training including reception/administrative staff and that all GPs have attended level 3 training in children’s safeguarding.

• That the practice maintains a log of all staff training and that mandatory training requirements are met for all staff.

• Ensure that environmental and legionella risk assessments are carried out and regularly reviewed.

• Ensure that infection control procedures are clearly embedded and include regular annual infection control audits with action taken, the appointment of a dedicated infection control lead and infection control training for all staff.

• Ensure that there is a system in place to monitor the use of prescription sheets stored in printers including ensuring they are locked away when not in use.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice