Care Quality Commission (CQC)

CQC - Follow-up Inspection Final Report July 2017

When the Practice was inspected and a report issued in December 2016, there were areas where the CQC inspector felt that the Practice needed to improve.  The Practice acted on the recommendations made by the CQC and the final full report from this follow-up inspection has now been published.  To view the full report please see the link at the bottom of this page. 

Ratings have been awarded on a four-point scale; ‘Outstanding’, ‘Good’; ‘Requires Improvement’, or ‘Inadequate’.

The table below shows the ratings awarded to the Clanfield Practice:

Response to CQC rating – December 2016

The Practice was rated “good” in the following areas:

Are services caring?

Are services responsive to people’s needs?

We feel this rating reflects the hard work our team puts into providing good patient care.

The areas where the CQC inspector felt that the Practice needed to improve were:

• “Ensure all staff receive appropriate training to carry out their role. In particular safeguarding, infection control and basic life support in accordance with practice policy.”

The Practice has now signed up to the Blue Stream Academy training resource. This will enable us to keep more effective and accurate records of the teams mandatory training and to ensure any outstanding training is completed within the designated time frame. 

• “Ensure that clinical audits are undertaken regularly to demonstrate clinical learning and development”

Although the GP’s have participated in a number of clinical audits throughout the year there has not been a formal clinical audit programme in place. This is in the process of being introduced so each GP can participate in their own audits and the results discussed with the other GP’s at a Practice meeting.

• Quality and Outcomes Framework data for 2014/2015 was used to rate the Practice with regards to services being effective. This data shows the Practice as lower than average in most areas but there has been a dramatic improvement in 2015/2016 data since introducing a named QOF lead GP. If the CQC could have had access to more current data at the time of the visit, the Practice would have been likely to have received and a “good” rating in a number of areas.

By acting on these 3 improvement areas, the Practice should be in a position to achieve an overall “good” rating in the near future.

The CQC Inspector also suggested the following improvements:

• Make sure appropriate sink taps are provided for hand washing – new taps to be purchased and fitted in the treatment room.

• Review the booking of appointments in advance – following patient feedback we have recently returned to booking appointments up to six weeks in advance.

• Ensure that patients’ conversations cannot be over heard in the reception area by patients queuing behind them – due to the building lay out this is not always possible but patients should be made aware that they can ask to speak to a member of staff in private if they prefer and where possible the arrangements will be made.

• Ensure that patients who are also carers are identified for support to be offered as needed – The Practice will review their process for identifying and providing support for carers.

• Ensure that staff who act as chaperones are trained to undertake the role – Arrangements will be made for non-clinical staff to undergo training and have DBS checks so they are appropriately trained to act as a chaperone.

Although the CQC visit was a challenging experience for all involved and the overall rating was “requires improvement”, the Practice accepts the recommendations made by CQC and will ensure they are implemented quickly and effectively. The Practice is also proud of the number of positive comments made throughout the full report and feel that they are reflective of the dedicated, hardworking team at Clanfield Surgery.