We have rated this practice as Inadequate overall.
We found that overall governance arrangements within the practice were ineffective which resulted in potential risks to patients. The practice was not consistently following its own policies and procedures:
- Our clinical searches found that the practice had not taken enough action to assess and manage risks to the patients, arising from MHRA safety alerts. However the quality of clinical care provided to patients, including those with long term conditions was of a good standard.
- There were gaps in systems to assess and manage health and safety risks, including ineffective policies and procedures, and absence of necessary assessments of risks including health and safety risk assessment.
- There were shortfalls in the management of medicines, specifically the management of emergency medicines and vaccine storage and handling.
- There were gaps in the fire safety processes including, absence of fire risk assessment, up to date staff training and regular fire drills.
- The governance arrangements for keeping proper records needed improvement.
- There was no evidence of a formalised and auditable process for clinical supervision, coaching and peer review for clinicians.
- The practice was not ensuring all staff training was up to date.
- Recording the detail of patient complaints and sharing of learning across staff needed to be improved.
We found breaches of regulations. The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
- 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:
- Continue to implement a programme to improve uptake for cervical screening and childhood immunisations.
- Review recruitment check procedures to ensure risk assessments are carried out for the re-employment of any staff.
- Make easy read materials available and patient information available in other languages and formats.
- Review the quality of the notes circulated following safeguarding meetings to prevent any misunderstanding of actions and decisions agreed.
https://www.cqc.org.uk/location/1-2147365283/inspection-summary