11th 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 Myrtle House Surgery on 19 January 2017. The overall rating for the practice was requires improvement with the key questions of safe and well-led rated as requires improvement. Action was required to mitigate identified risks and to review and improve the governance arrangements to ensure they were comprehensive. Systems in place also required review to ensure appropriate follow-up action was taken for patients identified as vulnerable. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Myrtle House Surgery website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 11 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 in our previous inspection on 19 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good. Our key findings were as follows:
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We saw evidence at this inspection that records of incidents were now in place and there was evidence of shared learning from these events including formal meetings and documentation of discussions.
- At this inspection, we saw evidence that the practice Health and Safety policy had been updated and a comprehensive risk assessment had been undertaken. All identified risks have been mitigated.
- We found at this inspection that an IPC audit had taken place, action taken as required and staff attended training in May 2017.
- At this inspection, we found that systems have been reviewed and all patients identified as vulnerable had an alert on their records.
- We saw evidence at this inspection that patient outcomes are now under ongoing review and achievement on the Quality and Outcomes Framework (QOF) had improved substantially.
- We found evidence of monitoring of staff updating their knowledge as policies were reviewed.
- We saw at this inspection that a training matrix had been introduced to monitor staff training. Personnel records remained poorly organised; however we saw evidence that this had been improved within two days of our inspection.
- At this inspection we saw that all clinical audit activity had been captured and that new protocols had been introduced to improve care and treatment.
- At this inspection, the practice showed us evidence of discussions regarding assisting patients who had a hearing loss. All staff had attended a meeting to discuss how to access translation services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice