Letter from the Chief Inspector of General Practice
We undertook a comprehensive inspection of The Boat House surgery on 5 November 2014. We have rated the overall practice as good. The practice was rated requires improvement in safe and good in the effective, caring, responsive and well led domains.
Our key findings were as follows:
The practice is rated as requires improvement for providing safe services. Patients were at risk of harm because systems and processes had not been implemented in a way to keep them safe. For example, medicines management and dispensing systems did not reflect national guidelines. The practice did not have a policy for the management, testing and investigation of legionella (a germ found in the environment which can contaminate water systems in buildings). There was no risk assessment to determine if action was required to reduce the risk of legionella infection to staff and patients. We found some of the information required by the regulation was not recorded in the individual staff files. The practice had a system in place for reporting, recording and monitoring significant events. Multi-disciplinary practice meetings took place where attendance included clinicians from other disciplines
The feedback from patients was very positive. Patients were satisfied with the service provided by the practice. Patients described staff as caring and helpful. Patients commented they were always listened to and involved in their treatment and care.
We found the service was responsive to patient’s needs. Patients we spoke with were generally happy with the appointment system. The results from the national GP survey showed, 96% patients said it was easy to get through to this surgery by phone. Ninety eight percent of patients said their last appointment was convenient and 95% of patients were able to get an appointment to see or speak to someone the last time they tried.
Patients’ needs were assessed and care and was planned and delivered in line with current legislation. Staff had received training appropriate to their roles and further training needs had been identified and planned. The practice was well led, and had a clear vision and strategy. The practice had a clear leadership structure and staff we spoke felt supported and valued.
The practice is rated as good for being well-led. The practice had a clear vision to deliver high quality care and promote good outcomes for patients. The practice had a clear leadership structure which had named members of staff in lead roles. However, we found the practice had not taken all measures to identify, assess and manage some risks.
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
- Ensure medicine management and dispensing systems are reviewed and reflect national guidelines.
- Ensure all information required relating to staff checks (such as references), identification documents, and evidence to confirm staff are physically and mentally fit to carry out their roles, are in place and available in staff records.
- Ensure risk assessments are documented to inform which members of staff required a Disclosure Barring Service (DBS) check and which members did not.
In addition the provider should:
- Introduce a legionella risk assessment and related management schedule.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice