Mayfield Surgery

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr. McCarthy and Partners on 5 and 16 June 2017. The overall rating for the practice was Good with Requires Improvement in Well Led. The full comprehensive report on the 5 and 16 June 2017 inspection can be found by selecting the ‘all reports’ link for Dr. McCarthy and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 October 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 5 and 16 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

• Staff who provided a chaperone service had been in receipt of chaperone training and been subject to disclosure and barring service (DBS) checks.

• Infection Prevention and Control (IPC) systems had been implemented and monitored; the IPC audit findings demonstrated that actions required included a timescale for completion to reduce risk. A legionella risk assessment had been completed in October 2017. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

• Fire safety checks were documented which included for example attendees at the fire evacuation drill.

• The provider had a basic general environment risk assessment in place.

• The practice had completed a thorough risk assessment of the window blinds and taken remedial action where appropriate.

• The provider had ensured that the comprehensive business continuity plan for major incidents such as power failure or building damage included emergency contact numbers for staff.

• Staff had received performance reviews.

• Staff had provided information on their immunity status. Actions in relation to this were still in progress including advice from the occupational health service and risk assessments for those staff without childhood immunisations.

• There was a formal process in place to monitor that NICE guideline and patient safety alerts were actioned and shared.

• The practice had received quotes and advice on their consideration of a hearing loop to take account of the practice demographic and the needs of their population groups and consideration into automated doors to improve patient access to the premises.

• The practice staff demonstrated awareness of the practice vision values and business strategy.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Continue to improve the collation of carers numbers documented on the practice carers’ register.

• Complete the actions in progress in relation to staff immunity status and any actions, or risk assessments in relation to staff that had not been not in receipt of childhood immunisations.

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 Dr. McCarthy and Partners on 5 and 16 June 2017. Overall the practice is rated as good with requires improvement in well led.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.

• The practice had the majority of systems to minimise risks to patient safety with exceptions. The exceptions included for example; ensuring all chaperones were in receipt of appropriate checks and training, completion of a legionella risk assessment and ensuring the systems in place for fire safety checks were fully documented.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Staff had received inductions but not all were well documented and not all staff had received annual performance reviews.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and 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 practice staff were however unaware of the practices documented mission statement or strategy to be able to understand the practice vision and values.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example:

• Chaperones must be in receipt of suitable training and be subject to disclosure and baring service (DBS) checks or have a completed risk assessment in place.

• Infection Prevention and Control (IPC) systems should be fully implemented and monitored;the IPC audit findings should be actioned in a timely manner to reduce risk; and a legionella risk assessment should be completed . (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

• Ensure fire safety checks are fully documented.

• Complete a general risk assessment including a risk assessment of the window blinds.

• Ensure that the comprehensive business continuity plan for major incidents such as power failure or building damage includes emergency contact numbers for staff.

• Ensure that staff are in receipt of regular performance reviews.

• Maintain all staffs full immunity status.

• Implement a formal process to demonstrate how the practice monitored that NICE guidelines and patient safety alerts were actioned.

The areas where the provider should make improvement are:

• Consider a hearing loop to take account of the practice demographic and the needs of their population groups and consider automated doors to improve patient access to the premises.

• Improve the collation of carers numbers documented on the practice carers’ register.

• Improve staff awareness of the practice vision values and business strategy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice