10 July 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 Devonshire Green Medical Centre and the branch site at Hanover Medical Centre on 9 November 2016. The overall rating for the practice was requires improvement with requires improvement in safe and well led. The full comprehensive report from 9 November 2016 can be found by selecting the ‘all reports’ link for Hanover Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 10 July 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 at our previous inspection on 9 November 2016. 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. Specifically, following the focused inspection we found the practice to be rated good for being safe and well led.
Our key findings were as follows:
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Recruitment checks to ensure staff were of good character had been completed. All clinical staff and staff who performed chaperone duties had received a Disclosure and Barring Service (DBS) check and there were references on file for new staff recruited since the last inspection.
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All staff had received safeguarding training relevant to their role as recommended in the Safeguarding Children and Young people: Roles and Competencies for Healthcare Staff 2014.
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All staff had received basic life support training as recommended in the Resuscitation Council (UK) Guidelines for staff working in a primary care organisation.
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The fire risk assessment had been reviewed. A fire drill had been carried out at both sites and maintenance checks of the fire alarm system were more regular although did not comply with the practice's Fire Safety Policy of being completed weekly at the Hanover Medical Centre site. These had been completed weekly at the Devonshire Green site.
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The legionella risk assessment had been reviewed and actions taken to mitigate the risks identified.
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A process to action safety alerts received by the practice had been implemented. However, there was no monitoring overview of these.
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A training matrix had been implemented to monitor what training staff had received and when it was due to be updated.
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.A system to monitor that clinical staffs’ registration with their professional body and medical indemnity cover for clinical staff was adequate and in date had been implemented.
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Cleaning schedules had been implemented to monitor what cleaning had taken place and the frequency.
Areas the practice should improve:
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The practice should implement a central log or monitoring overview of safety alerts received and action taken for staff to reference.
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The practice should carry out maintenance checks in line with the Fire Safety Policy.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice