We carried out an announced comprehensive inspection at The Northolme Practice on 9 January 2019. The overall rating for the practice was good, with requires improvement for providing safe services.
The full comprehensive report on the January 2019 inspection can be found by selecting the ‘all reports’ link for The Northolme Practice on our website at .
This inspection was an announced focused inspection, carried out on 8 January 2020 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified at our previous inspection on 9 January 2019.
This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as good. The key question of are services safe is now also rated as good.
At our previous inspection on 9 January 2019 we rated the practice as requires improvement for providing safe services as disclosure and barring service (DBS) checks had not been carried out for staff performing chaperone duties, and risk assessments to this effect had not been completed. In addition, infection prevention and control processes were not sufficiently thorough; actions from premises risk assessments had not been carried out and window blind cords were not secured in line with safety regulations in all cases. We also found that systems for logging and tracking blank prescriptions were not sufficiently thorough, and staff vaccination status was not reviewed in line with department of health guidelines.
At this inspection we found that these issues had been addressed, and additional improvements had also been implemented.
Our key findings were as follows:
- The provider had reviewed their approach to DBS checks. These were completed for all staff, including those undertaking chaperone duties.
- Infection prevention and control processes were thoroughly implemented and understood by all.
- Actions from premises risk assessments had been completed.
- Systems for logging and tracking blank prescriptions had been improved.
- Window blind cord loops were appropriately secured in line with legal requirements.
- Staff vaccination status had been reviewed and staff signposted to receive any outstanding immunisations.
- Appraisals for all staff, including non-clinical staff had been scheduled within timescales.
- Systems for dissemination of clinical updates were improved and embedded.
- Systems for identifying vulnerable adults on clinical records had been developed and were being rolled out.
The areas where the provider should make improvements are:
- Update their recruitment policy to accurately reflect the decisions made in relation to staff DBS checks.
- Develop formal written guidance to assist non-clinical staff in identifying and appropriately signposting patients with urgent or less urgent needs.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care