Chacewater Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at the Chacewater Health Centre on 21 July 2016. This was to review the actions taken by the provider as a result of our issuing two legal requirements. In January 2016 the practice did not have safe systems in place for the safe management of medicines and appropriate risk assessments were not in place to ensure staff within the practice had received appropriate checks and up to date mandatory training.

Overall the practice has been rated as Good following our findings, with safe, effective and well led now rated as good. This report should be read in conjunction with our report published on 20 April 2016 where the responsive and caring domains were rated as Good.

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

• The provider had carried out Disclosure and Barring checks (DBS) (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable) for all staff working within the practice.

• A new training policy had been written, including induction training for all new staff and a spreadsheet demonstrating training completed by existing staff.

• A comprehensive induction programme and protocols for the pre-employment of Locum GPs had been put in place.

• New procedures had been put in place to ensure that national guidance was followed for the safe storage of blank prescription forms and medicines being stored at the correct temperatures.

• New procedures had been introduced for the dispensary staff to follow regarding the National Reporting and Learning System (NRLS) reporting system. This system enables patient safety incident reports to be submitted to a national database. The data is then analysed to identify hazards, risks and opportunities to improve the safety of patient care.

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 Chacewater Health Centre on 27 January 2016. Overall the practice is rated as Requires Improvement

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that 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 provider was aware of and complied with the requirements of the Duty of Candour.

There were areas of practice where the provider must make improvements are:

• The provider must ensure there are risk assessments in place for all staff in roles deemed not to need a Disclosure and Barring Service check. Staff undertaking chaperone duties must have received (DBS) checks.

• New staff should have an induction that includes mandatory training.

• Written protocols for pre employment for Locum GPs should be in place.

• Review procedures for storing and recording blank prescriptions to ensure national guidance is followed and ensure that processes are in place to check that medicines are stored at the appropriate temperature

• Dispensary staff must be aware of National Reporting and Learning System (NRLS) reporting and feel able to use it. There should be consistency of approach to errors and near misses across both sites.

• The provider must have in place a formal review process to check training was being completed

The areas where the provider should make improvement are:

• The provider should review governance processes to ensure all aspects of recruitment, medicines management and training support the practices service quality and improvement plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice