Oakfield Surgery

Oakfield Road, Aylesbury, Buckinghamshire HP20 1LJ

Care Quality Commission

Report on actions we plan to take to meet CQC essential standards

Regulated activity(ies) Regulation

Diagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014

Good governance

How the regulation was not being met:

The registered person did not ensure such systems or processes were in place to enable the registered person, in particular, to—

 

2a. assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services);

 

b. assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.

 

Regulation 17 (2)(a)(b)

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

Following the retirement of our Practice Nurse we have employed a new nurse who is fully trained in Infection Control.

We are re-writing our policies to reflect the changes and these will be discussed with our new nurse and our HCA who will be responsible for infection control within the surgery.

All staff will now receive annual training in infection control.

New members of staff will receive Infection Control training within our newly developed ‘New Employee Check List’ as part of their induction.

 

All building checks are to be carried out on a regular basis and recorded on a spreadsheet and paperwork filed in corresponding folders.

 

Our Gas boiler has now had a full inspection and a pass certificate.

We have also had an Asbestos Inspection and all recommendations have been carried out.

All recommendations made following our Legionella Inspection have now been completed.

PAT testing has been booked for 25/6/15

Medical Equipment Test and Calibration have been booked for 30/6/15

Who is responsible for the action? Kate Carty – Practice Manager
How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this?

Improvements will be monitored by audits performed by our Practice Nurse/HCA and any areas identified as not meeting with the regulation will be reported to the Practice Manager who will in turn assess and respond appropriately to rectify.

We have developed a spreadsheet to record when these checks are carried out and what the outcomes are and any actions taken.

Who is responsible? Kate Carty – Practice Manager
What resources (if any) are needed to implement the change(s) and are these resources available?
Infection Control training will be provided by the Infection Control trained Nurse and any other training will be provided as necessary.
Date actions will be completed:

Our new nurse starts on 1/5/15 and our in-house training will be on 9/9/15

Policy changes etc by 30/6/15

 

Regulated activity(ies) Regulation

Diagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014

Safe care and treatment

How the regulation was not being met:

The registered person did not protect service users against the risks associated with the unsafe use and management of medicines, by means of the making of appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration, and disposal of medicines used for the regulated activity.

Regulation 12 (g).

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

Our HCA will be responsible for the checking and ordering of all stock within the surgery on a monthly basis, including the Doctors Rooms and bags and will make sure all stock is within date.

Our Practice Nurse will be responsible for the ordering and checking of Immunisations.

Who is responsible for the action?

Shireen Kurji – Practice Nurse

Denise Savage – HCA

How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this?

Our HCA has taken on more hours and is currently studying for her NVQ in Clinical Health and Social Care. She has been given allotted time to do checks and audits. These will be recorded on a spreadsheet when done which will, in turn, be checked by Practice Manager.

We have a new Protocol for ordering, storing and handling vaccines and are in the process of writing a new protocol for the checks and auditing.

 

Who is responsible? Kate Carty
What resources (if any) are needed to implement the change(s) and are these resources available?
New protocols/policies are being put in place to implement these changes.
Date actions will be completed: 31.7.15

 

Regulated activity(ies) Regulation

Diagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 19 HSCA (RA) Regulations 2014

Fit and proper persons employed

How the regulation was not being met:

The registered person did not ensure –

1. Persons employed for the purposes of carrying on a regulated activity were

a.    be of good character.

Regulation 19 (1)(a)

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

Following the CQC visit and its subsequent report – we have been proactive in formalising how we record Employee records and have revised the way we check our staff to conform with this Regulation

All staff are in the process of having DBS checks regardless of length of service or job role.

All clinical staff have provided evidence that they are registered with the relevant professional body and these have been checked and verified by the Practice Manager and recorded.

Who is responsible for the action? Kate Carty – Practice Manager
How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this?

A check list for new employees is being developed for all new members of staff to provide all the correct information.

Identity Checks

The right to work

Professional registration & qualification

Employment history and reference

Work health assessment

Doctors Registration/Indemnity/Hep B status/Appraisal will be checked annually.

Who is responsible? Kate Carty – Practice Manager
What resources (if any) are needed to implement the change(s) and are these resources available?
N/A
Date actions will be completed: 31/6/15

 

Regulated activity(ies) Regulation

Diagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 18 HSCA (RA) Regulations 2014

Staffing

How the regulation was not being met:

2. Persons employed by the service provider in the provision of regulated activity did not:

(a) receive appropriate support, training and personal development as was necessary to enable them to carry out the duties they were employed to perform.

Regulation 18 (2)(a).

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

A full training timetable has been developed and is being provided to all staff within the practice on Protected Learning days.

New reception staff are to have a training programme in place and a member of staff to shadow them.

Clinical staff are to attend relevant training to maintain the necessary skills to carry out their job role. Study leave is provided for all clinical staff.

All admin staff have received an appraisal and personal development plans have been discussed.

Our HCA will be supervised by our new nurse and any competencies checked to make sure she is compliant.

Who is responsible for the action? Kate Carty – Practice Manager
How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this?

Appropriate checks are being put in place to make sure all members of staff receive training relevant to their role.

Professional development will be encouraged and mandatory training provided.

A spreadsheet has been developed and is updated on completion of any training done by a member of staff. This will enable us to keep a check on who needs training in any particular area.

Who is responsible? Kate Carty – Practice Manager
What resources (if any) are needed to implement the change(s) and are these resources available?
Appropriate training courses are required.
Date actions will be completed: 31/6/15

 

How will people who use the service(s) be affected by you not meeting this regulation until this date?

 

Completed by:

(please print name(s) in full)

 

Kate Carty

Dr Sajid Zaib

 

Position(s):

Practice Manager

Senior Partner

Date: 23 April 2015