6 April 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 Westbourne Surgery on 19 August 2015. The overall rating for the practice was good. However, a breach of the legal requirements was found which resulted in the practice being rated as requires improvement for providing safe services. The full comprehensive report on the August 2015 inspection can be found by selecting the ‘all reports’ link for Westbourne Surgery on our website at www.cqc.org.uk.
In addition to the breach of regulation, at the inspection on 19 August 2015 we also said the practice should consider the following area:
-
The practice should review the provision of emergency equipment and undertake a risk assessment in regard to the decision not to have a supply of emergency oxygen or a defibrillator on the premises.
This inspection was an announced focused inspection carried out on 6 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 19 August 2015. This report covers our findings in relation to those requirements.
The practice had not made sustained improvements to meet the legal requirements in the key question of safe and remains rated as requires improvement.
Our key findings were as follows:
-
The practice had not undertaken an assessment for the risk of legionella, fire safety, emergency equipment or undertaken an infection prevention and control (IPC) audit or completed a fire drill within the last 12 months. Mandatory refresher training in fire safety and IPC had not been completed by relevant staff.
The areas where the provider must make improvement are:
-
The provider must assess the risks to the health and safety of service users and do all that is reasonably practicable to mitigate any such risks. Risk assessments to monitor the safety of the premises in respect of infection prevention and control (IPC) and legionella had not been completed. A supply of emergency oxygen was not held at the practice and no risk assessment had been completed to support this decision.
-
Ensure relevant staff update their mandatory training in respect of fire safety, fire evacuation and IPC to ensure they have the appropriate training to meet their learning needs and to cover the scope of their work.
The areas where the provider should make improvement are:
-
The practice should risk assess and review the arrangements for emergency equipment as there was no defibrillator held at the practice.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice