Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Crook Log Surgery 19 Crook Log, Bexleyheath, DA6 8DZ Tel: 08444773340 Date of Inspection: 30 July 2014 Date of Publication: September 2014 We inspected the following standards to check that action had been taken to meet them. This is what we found: Safeguarding people who use services from Met this standard abuse Requirements relating to workers Met this standard Assessing and monitoring the quality of service Met this standard provision | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 1 Details about this location Registered Provider Crook Log Surgery Registered Manager Dr Winnie Kwan Overview of the Crook Log surgery is a doctors practice with two partners service and is situated in the London borough of Bexley. Type of services Doctors consultation service Doctors treatment service Regulated activities Diagnostic and screening procedures Family planning Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 2 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Page Summary of this inspection: Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 4 Our judgements for each standard inspected: Safeguarding people who use services from abuse 6 Requirements relating to workers 7 Assessing and monitoring the quality of service provision 8 About CQC Inspections 10 How we define our judgements 11 Glossary of terms we use in this report 13 Contact us 15 | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 3 Summary of this inspection Why we carried out this inspection We carried out this inspection to check whether Crook Log Surgery had taken action to meet the following essential standards: • Safeguarding people who use services from abuse • Requirements relating to workers • Assessing and monitoring the quality of service provision This was an announced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 30 July 2014, talked with people who use the service and talked with staff. We used information from local Healthwatch to inform our inspection. What people told us and what we found We carried out this inspection to ensure that the provider had completed the required improvements and addressed the areas of non-compliance found at our inspection on the 13 and 19 February 2014. People we spoke with were generally happy with the care they received although people did say that they were still experiencing difficulties with the telephone lines and in getting through to speak to staff. One person told us "I cannot talk highly enough about this practice, I give my GP ten out of ten" and another described the care they received as "good" although they said they didn't often need to come to the surgery". We found that people felt listened to by the general practitioners (GPs) At the inspection on the 29 July 2014 we found that the provider had made the required improvements. We found that people were protected from abuse as the staff had received the appropriate safeguarding training for children and adults and that there were appropriate recruitment checks in place to ensure only suitable people were employed. The practice had made improvements to ensure the quality of the service was monitored and that information was disseminated to all staff to ensure that learning from complaints and significant events took place. You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 4 number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 5 Our judgements for each standard inspected Safeguarding people who use services from abuse Met this standard People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement During our inspection on the 13 and 19 February 2014 we found that the provider was not meeting this standard. We found that the provider did not always ensure that people were protected from the risk of abuse as staff had not received the appropriate training. Following our inspection the provider submitted an action plan and outlined the improvements that would be made to ensure they were meeting this essential standard. At our inspection on 30 July 2014 we found the provider had made the required improvements. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The provider had a child protection policy in place and a lead clinician for safeguarding children and adults. We saw that the safeguarding children and vulnerable adult's policy had been revised and identified the names of the lead GPs for the safeguarding of children and vulnerable adults. The practice manager confirmed that all staff had now received the appropriate training and provided evidence to confirm this. For example we saw that all clinical and administrative staff had undertaken level 1 training in June 2014. We saw that one of the lead GPs had also received level 3 training for both children and adults. We saw confirmation that the other principal GP had training arranged for November covering both children and adults. We spoke with staff at the practice who confirmed that they had received the training and were aware of the reporting mechanism for reporting any concerns either via member of the clinical staff or directly to the local authority. | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 6 Requirements relating to workers Met this standard People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by, suitably qualified, skilled and experienced staff. Reasons for our judgement During our inspection on the 13 and 19 February 2014 we found that the provider was not meeting this standard. We found that the provider did not always ensure that people were cared and supported by suitably qualified and skilled staff; as the provider's recruitment policy was not consistently followed. Following our inspection the provider submitted an action plan and outlined the improvements that would be made to ensure they were meeting this essential standard. At our inspection on 30 July 2014 we found the provider had made the required improvements. The provider had a recruitment policy in place which outlined the checks to be undertaken when new staff were employed. This included criminal record checks, references, qualifications, proof of identity, proof of address and checks on clinical registration documents. We reviewed a selection of staff files which included a new member of staff, as well as the staff files that had been of concern during the February 2014 inspection. We found that the correct checks had been undertaken prior to staff starting at the surgery and that each file held two references. The staff files contained evidence to show that people also had health checks undertaken prior to starting work and that new and locum staff received a formal induction programme to ensure they were familiar with their role and the practice policies and procedures. This confirmed that the provider had a consistent approach to the staff recruitment and that suitable and appropriately qualified staff were employed. The practice manager told us that they had not as yet completed an audit of their staff files but had implemented a check list for staff to complete when they recruited new staff. We were told that the practice had just recruited a new additional manager to support the administration team and the audit would be undertaken as soon as the new member of staff had settled into her role. | Inspection Report | Crook Log Surgery | September 2014 www.cqc.org.uk 7 Assessing and monitoring the quality of service Met this standard provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive. Reasons for our judgement During our inspection on the 13 and 19 February 2014 we found that the provider was not meeting this standard. We found that the provider did not have effective systems in place to regularly assess and monitor the quality of care. Following our inspection the provider submitted an action plan and outlined the improvements that would be made to ensure they were meeting this essential standard. At our inspection on 30 July 2014 we found the provider had made the required improvements.