Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection at Beech House Surgery on 25 April 2016. The overall rating for the practice was good. However, the practice was rated as requires improvement for providing safe services. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Beech House Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 25 October 2017 to confirm that the practice had carried out their plan to make the improvements that we identified in our previous inspection on 25 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
The practice is now rated as good for providing safe services; overall the practice rating remains good
Our key findings were as follows:
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The process for managing repeat prescriptions was embedded in the practice. All requests for repeat prescriptions were directed to the duty doctor before being sent to the dispensary or reception for collection. All repeat prescription requests were dealt with on the day and were monitored to ensure that none had been left unattended to at the end of the day.
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PGDs and PSDs were all signed and up to date. PGDs were reviewed on a three monthly basis to ensure all were in date and action was taken regarding any that were due to expire within the three month period.
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An identified nurse had now completed the specialist course on infection, prevention and control. There was a quarterly walkthrough audit undertaken and a comprehensive annual audit each February. Legionella risks were managed by the practice and training had been provided by an external provider.
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A new door lock with a key pad had been placed on the access door to the paper medical records ensuring security could be maintained.
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Music was now piped into the waiting area outside the nurses’ room reducing the risks of breach of confidentiality from conversations being overheard.
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The practice had a comprehensive training matrix identifying all training completed and due dates.
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There was an appraisal system that included assessing competencies and the HCAs were observed a minimum of three times a year by the nurse to ensure competencies were maintained.
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Clinical and non-clinical alerts were received into the practice via a surgery email address as well as the practice manager to ensure that in the absence of the practice manager alerts would be dealt with by a nominated person.
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GP letters were monitored bi-weekly to ensure that all letters had been dealt with by the GPs. Any GPs with unattended letters were alerted to this by the practice manager.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice