- GP practice
Drs Bryan, Hadley, Jones & Chan Also known as Dale Medical Practice
All Inspections
25 May 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection at Drs Bryan, Hadley, Jones and Chan on 21 March 2016.
We found that there was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Fit and proper persons employed:
- The provider could not evidence that the appropriate recruitment checks had been completed on all staff employed.
A requirement notice was served on the practice in respect of the breach of regulations. The practice subsequently sent us an action plan to say what they would do to meet legal requirements.
The overall rating for the practice at the original inspection was good and the full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Drs Bryan, Hadley, Jones and Chan on our website at www.cqc.org.uk.
We undertook an announced focused inspection on 25 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 March 2016 inspection. We visited the practice to review the improvements made. This report only covers our findings in relation to those requirements and additional improvements made since our last inspection. The legal requirements had been met and the rating in the safe key question changed from requires improvement to good.
Our key findings were as follows:
- The practice had completed a disclosure and barring service (DBS) check or risk assessment for all staff employed.
- The practice had identified and planned training needs for practice staff. Training had been completed or planned.
- Staff had received an annual appraisal.
- There was a risk log and completed risk assessments for each risk identified.
- Monitoring checks mentioned in the legionella risk assessment had been completed (Legionella is a bacterium which can contaminate water systems in buildings).
- There was an effective recall system for patients with learning disabilities to have annual health checks completed.
- Learning from complaints was seen to have been shared with staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
21 March 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Drs Bryan, Hadley, Jones and Chan on 21 March 2016. Overall the practice is rated as good.
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the Care Quality Commission (CQC) at that time.
Our key findings were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed.
- Staff had received some training appropriate to their roles. Informal in house training courses did not always provide staff with sufficient knowledge.
- The practice had not performed risk assessments or completed disclosure and barring service (DBS) checks on staff employed.
- The practice had an established, well supported multi-disciplinary team approach to providing patient care.
- Patients said they were treated with dignity and respect. A number of patients with more complex needs complimented the practice on the treatment and care provided by the practice.
- Information about services and how to complain was available and easy to understand.
- Patients told us they could get urgent appointments when they needed one. Appointments were 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 the management. There was evidence that the practice proactively sought and acted on feedback from staff and patients.
We saw areas where the practice must improve. The practice must:
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Complete a disclosure and barring service (DBS) check or risk assessment for all staff employed.
We saw areas where the practice should improve. The practice should:
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Identify and plan training needs for practice staff.
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Ensure all staff receive regular appraisals.
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Compile a risk log and complete risk assessments for each risk identified.
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Complete monitoring checks mentioned in the legionella risk assessment (Legionella is a bacterium which can contaminate water systems in buildings).
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Implement a robust recall system for patients with learning disabilities to have annual health checks completed.
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Share learning from complaints with staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice