4 October 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Barnsley Road Surgery on 14 February 2017. The overall rating for the practice was good with requires improvement in well-led. The full comprehensive report from 14 February 2017 can be found by selecting the ‘all reports’ link for Barnsley Road Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 4 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 14 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated good with requires improvement for being well-led.
Our key findings were as follows:
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Some risks to patients were assessed and managed, others required review. For example, the practice could not provide a fire risk assessment and fire safety systems and procedures were not clear. An infection control audit had been completed although an action plan to address the areas identified for improvement had not been developed at the time of the inspection and there were shortfalls in the monitoring of some cleaning schedules.
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A system to track the use of blank prescriptions throughout the practice had been implemented. However, a record was not maintained when blank prescriptions were received into the practice.
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A monitoring log had been implemented to record medical indemnity cover and registration status with the professional bodies for all clinical staff.
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Actions taken after safety alerts were received by the practice had been documented.
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Staff had not received regular appraisal and some staff were overdue training updates. However, training had recently been arranged for staff and all staff had a date planned for an appraisal in October 2017.
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The procedure for monitoring the medical fridge temperatures had been reviewed and updated.
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The access walkway between the main building and the annex had been resurfaced.
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The system for recording verbal complaints had been reviewed and formalised.
The areas where the provider must make improvements are:
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Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
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Arrange for staff to receive regular appraisals as part of the appraisal system.
- Review practice policies to ensure they are current and reflect custom and practice.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice