Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Roslea Surgery on 23 November 2016. The overall rating for the practice was good with the key question of safe rated as requires improvement. The full comprehensive report on the November 2016 inspection can be found on our website at
http://www.cqc.org.uk/location/1-554172576
This inspection was a desk-based review carried out on 13 July 2017. This was 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 23 November 2016. This report covers our findings in relation to those requirements.
Overall the practice is now rated as good.
Our key findings were as follows:
- At the inspection in November 2016 we found that the practice had not addressed the risks associated with an infection control audit carried out in January 2016. The audit had highlighted some issues related to the cleaning of the premises and to the disrepair of some flooring and wall tiles. It had also highlighted that some patient blood tests were being undertaken in a carpeted room. At this desk-based review we saw evidence that the practice had replaced damaged flooring in those areas identified by the audit, including the laying of clinically-acceptable flooring to replace the carpet where patient blood tests were carried out. We also saw evidence that the practice had recruited the services of a cleaning company and we saw audits of their work that had been undertaken.
- At our previous inspection, we identified that the surgery did not have a legionella risk assessment for the building (legionella is a term for a particular bacterium which can contaminate water systems in buildings). For this inspection, the practice provided evidence to show that a legionella risk assessment had been conducted and that the practice was in the process of seeking professional guidance as to how identified risks could be mitigated.
- At the inspection in November 2016 we saw that there had been no health and safety risk assessments completed for people using the building. We saw that the practice had since produced these risk assessments and had audited all areas of risk.
- In November 2016 we saw that there had been no fire risk assessment carried out for the building and that there were no weekly tests of the fire alarm or documented checks of escape routes and emergency lighting. The practice supplied evidence at this inspection to show that there had been a fire risk assessment carried out on 3 July 2017 together with weekly documented fire alarm tests and a fire evacuation check.
- At our previous inspection, we saw that the practice did not have a practice specific policy for the safeguarding of vulnerable adults. At this desk-based review, we saw evidence of this policy which we were told was available to all staff and stored on the practice computer.
- At the inspection in November, we found that the practice was not actively identifying patients who were carers. Following this inspection, the practice sent us evidence that they had reviewed the process of identifying carers and that the number of carers on the practice register had increased from 25 to 287 (3.4% of the practice list).
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice