Archived: Old Hall Surgery

We carried out an announced comprehensive inspection of Old Hall Surgery on 22 January 2019 as part of our inspection programme. The overall rating for the practice was good, however we rated the practice as requires improvement for safe. The full comprehensive report on the January 2019 inspection can be found by selecting the ‘all reports’ link for Old Hall Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 10 June 2019 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 22 January 2019. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as Good.

Our key findings were as follows:

• The system for recruiting staff had been reviewed to ensure only fit and proper persons were employed and the provider had ensured there was a training plan in place to ensure all staff completed the training they needed for their roles.
• The provider had taken action to address the areas where we advised them that improvements should be made. Improvements had been made to the procedures for the management of prescriptions and medication reviews. The system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing were appropriate had been formalised.
• At our previous inspection on 22 January 2019, we advised the provider that the security of patient records should be reviewed to protect from risk of damage and inappropriate access. At this inspection, this has not been fully addressed, however the provider told us the action being taken to address this issue.

The areas where the provider should make improvements are:

• The security of patient records should be reviewed to protect from risk of damage and inappropriate access.

We carried out an announced comprehensive inspection at Old Hall Surgery on 22 January 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

• There were shortfalls in the required information to demonstrate staff were suitable for employment.
• The practice was not able to show all clinical staff had completed fire safety, adult safeguarding, information governance and infection control training.

We rated the practice as good for providing effective, caring, responsive and well-led services.

We found that:

• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice monitored patient access to services. There had been a number of changes to the clinicians at the practice but a plan was in place to address this by providing greater continuity.
• The practice organised and delivered services to meet the needs of patients.
• There was a system in place for investigating and responding to patient feedback including complaints.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We saw an area of outstanding practice:

Two administrative staff at the practice had developed and kept updated a booklet for patients over 75 which gave useful information about local health and social care services and practical advice such as how to keep healthy over winter and eating well on a budget.

The area where the provider must make improvements are:

• Systems and processes must be in place to ensure specified information is available regarding each person employed and to demonstrate that all staff have received training suitable for their role.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• The security of patient records should be reviewed to protect from risk of damage and inappropriate access.
• Formalise the system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing are appropriate.
• Evidence of physical and mental suitability of staff for their role to be formally recorded
• Review the safety of prescriptions left in printers overnight or when the clinical rooms are not in use.
• Review the system for ensuring medication reviews are carried out in a timely manner and continue to monitor adherence to the revised procedure.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice