Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Axbridge and Wedmore Practice on 15 May 2015. Following our comprehensive inspection overall the practice was rated as requires improvement specifically for the safe and well led domains. Following that inspection we issued two requirement notices. These notices were due to a breach of Regulation 15 of The Health and Social Care Act (Regulated Activity) Regulations 2014, Premises and Equipment and Regulation 17 Good Governance. The requirement notices were for the practice to implement the necessary changes to ensure patients who used the service were protected against the risks associated with infection prevention, the other requirement notice was for the practice to monitor the quality and safety of the service. A copy of the report detailing our findings can be found on our website at www.cqc.org.uk.
Our previous key findings across the areas we had inspected were as follows:
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The practice needed to ensure there was a building maintenance programme in place.
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The practice needed to ensure there was a process to undertake regular risk assessments of the environment in order to identify any potential risks to patients’ safety.
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The practice needed to ensure the cleaning schedule was effective, in order to maintain the hygiene and cleanliness of the practice.
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The practice needed to review the protocols they had in place for patient safety, to ensure staff was able to put them into practice, in the areas such as. emergency protocols, cold chain protocols, safeguarding protocols.
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The practice needed to fully implement the recruitment policy to evidence that patients were protected from the risk of the employment of unsuitable staff.
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The practice needed to ensure staff were appropriately trained for the roles they fulfilled such as the administering of vaccinations and, chaperone training.
We had also found in addition the provider should:
We carried out an announced focused inspection at Axbridge and Wedmore Practice on 20 June 2016 to follow up the requirements and to assess if the practice had implemented the changes necessary to ensure patients who used the service were protected against the risks associated with infection prevention and lack of monitoring of the quality and safety of the service.
Overall the practice is now rated as good.
Our key findings across the areas we inspected were as follows:
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The practice had a building maintenance programme in place and had addressed areas of concern such as aspects of safety entering and leaving Wedmore Surgery, decoration and refurbishment.
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Risk assessments to identify and monitor risks to the environment were implemented and reviewed regularly.
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Cleaning schedules were in place and practice buildings were kept clean and hygienic.
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Protocols had been reviewed in updated and followed by staff, such as emergency procedures, use of the cold chain and safeguarding vulnerable adults and children.
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The records for recruitment showed that some but not all aspects of their recruitment policy and procedure had been recorded in detail appropriately.
The areas identified during this focused inspection, where the provider should make improvement are:
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice