The intention of sharing the content of this report is to assist practices that have not yet been inspected. They can use the summarised version of the report to identify risk areas in their own practice, creating a suitable action plan to reduce the associated risk prior to inspection.
We understand how painful and damaging a CQC inadequate report is to practice and its team. If you have been personally affected by this report please get in touch. We will offer a listening ear.
If you need more formal support we would recommend the “Looking after you team”. They offer an non-judgmental coaching support service: https://www.england.nhs.uk/supporting-our-nhs-people/support-now/looking-after-you-confidential-coaching-and-support-for-the-primary-care-workforce/looking-after-you-too/
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Regulation 17 HSCA (RA) Regulations 2014 Good
governance
• The practice failed to demonstrate they had an effective
quality improvement programme in place, which would
ensure safe and effective care to all patients.
• The practice failed to evidence that they had oversight
of the training undertaken or required by staff. This
training included safeguarding of children and adults,
Equality and Diversity and Basic life support.
• The practice failed to evidence that they had a safe
policy and system to ensure that full summaries of
patient records were managed effectively.
• The practice failed to evidence that the IPC audit and
waste management audit were wholly effective.
• The practice did not demonstrate that all staff had
received appropriate support, training, appraisal and
assessment to ensure they were able to carry out their
duties.
• The practice did not evidence that all staff were aware
of or supported to report significant events.
Regulation 12 HSCA (RA) Regulations 2014 Safe care and
treatment
• The practice did not evidence a safe system to ensure
patients on high-risk medicines were appropriately
managed in a timely way.
• The practice system for managing patient and
medicines safety alerts did not ensure medicines were
prescribed safely. We found patients that had been
affected by alerts had not been appropriately reviewed
and the risks to the patient not discussed with them.
• The practice did not evidence that all patients had a
structured and comprehensive medicines review.
• The practice did not evidence a safe system to ensure
all patient electronic tasks sent to administration staff
members were managed effectively.
• The practice did not have oversight of the DBS status of
all staff members.
• The practice did not have oversight of the
immunisation status of staff who may be at risk of
harm.
• The practice did not to ensure competency checks were
undertaken to ensure staff were competent to
undertake their duties.
• The practice had failed to carry out appropriate risk
assessments.
• The practice failed to ensure standard operating
procedures for the dispensaries were maintained. We
also found other concerns with the dispensaries.
• The practice did not have a process in place for
identifying and managing out of range refrigerator
temperatures.
https://api.cqc.org.uk/public/v1/reports/8b12c664-da4f-4486-a0ac-f3355fa06e10?20230301080049
https://s3-eu-west-1.amazonaws.com/dpub.evidence/KN7DJV977TVYUY/KN7DJV977TVYUY-EA.pdf