Our reference: INS1-584950610
CarolTaylor
PuddletownSurgery
2AAthelhamptonRoad
Puddletown
Dorchester
Dorset
DT28FY
14October2015
Care Quality Commission
Health and Social Care Act 2008
Inspection reportand report on the action you plan to take
Location name: PuddletownSurgery
Location ID: 1-545972022
Dear MsTaylor
Please find enclosed a copy of our final report following our recent inspection of PuddletownSurgery. Please make this report readily available for people who use the service.
Your inspection report sets out the ratings for your service. Our ratings are based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data as well information you and other local organisations have provided.
We have developed characteristics to describe what outstanding, good, requires improvement and inadequate looks like for each of the five key questions and population groups.
Ratings have been awarded on a four-point scale; ‘Outstanding’, ‘Good’; ‘Requires Improvement’, or ‘Inadequate’.
The table below shows the ratings your location has been awarded:
Safe / Effective / Caring / Responsive / Well-led / Overall population groupOlder people / Requires Improvement / Good / Good / Good / Good / Good
People with long term conditions / Requires Improvement / Good / Good / Good / Good / Good
Families, children and young people / Requires Improvement / Good / Good / Good / Good / Good
Working age people and the recently retired / Requires Improvement / Good / Good / Good / Good / Good
People in vulnerable circumstances / Requires Improvement / Good / Good / Good / Good / Good
People experiencing poor mental health / Requires Improvement / Good / Good / Good / Good / Good
Overall domain / Requires Improvement / Good / Good / Good / Good
Overall location / Good
A request for a review of ratings can only be made on the grounds that we have not followed our published process. If you think that we have not followed this process you can request a review. To do so you must first tell us within 5 working days of the publication of your report(s) that you intend to request a review by submitting this online form:
You will then be provided with instructions on how to submit your full request for review.
In this application you must say in what way we have not followed the published process, and which ratings you think have been affected. You can only request a review of ratings once after an inspection, so please ensure that you include all of the relevant ratings in your request. Please note that requests for reviews of ratings can lead to ratings being changed ‘downwards’ as well as ‘upwards’ or remaining the same.
We will publish this reporton our website shortly.
When we have publishedthis report you can see the contents and download a PDF version by clicking on this link:
Once published, you can see this at any time by following these steps:
- Go to the CQC website
- Click the appropriate tab for your type of service.
- Type in the name of your provider or location– if it appears automatically, click on it to jump to your profile page or click the 'search' button.
- Click on your location, your report will be on your profile page.
As a result of the judgement(s) made in our inspection, we have set compliance actions.These compliance actions can be found under the section of our report called, 'Action we have told the provider to take'.
Under Regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, you must send us a written report of the action you are going to take to achieve compliance with the Health and Social Care Act 2008, associated regulations and any other legislation we have identified you are in breach of.
If you have already sent us a report since our inspection about any of these actions, you do not need to include them in your new report.
You must return the report to us by 6 November 2015.
We have attached a template that you can use to write your report. It is important that you cover all the points in the template.
We would prefer you to send your report to us by email to:
If you are unable to do so, please post it to the address below.
Please include our reference number (INS1-584950610) in any letter or email you send with the report as it may cause a delay if you do not.
You should inform usin writing when you have completed the actions in your report and can confirm you meet the Health and Social Care Act 2008.We will check to make sure that you have taken action to meet this legislation and will report on our judgements.
If you have any questions about this letter, you can contact our National Customer Service Centre using the details below:
Telephone: 03000 616161
Email:
Write to:CQC PMS Inspections
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Yours sincerely,
Amanda Hames
CQC Inspector
Enclosed:
- Final Report
Report on actions you plan to take to meet CQC essential standards
Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action.
Account number / 1-545972022Our reference / INS1-584950610
Regulated activity(ies) / Regulation
- Diagnostic and screening procedures
- Family planning services
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
Fit and proper persons employed
How the regulation was not being met:
We found that the registered person had not ensured that persons employed for the purposes of carrying on a regulated activity were of good character and that information specified in Schedule 3 was available in relation to each such person employed and such other information as appropriate.
- Checks missing included conduct in previous employment, eligibility to work in the UK, employment history, disclosure and barring service check (or awritten rationale why such a check was not required) and photographic identification.
Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve
Carry out DBS checks on all employees who currently do not have a DBS check
Carry out DBS checks on all future employees
Make written requests for references for all new employees
Who is responsible for the action? / Carol Taylor
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?
The Practice Recruitment protocol has been amended to reflect the importance of carrying out these procedures and is to be adhered to for all future episodes of recruitment.
Who is responsible? / Carol Taylor
What resources (if any) are needed to implement the change(s) and are these resources available?
No extra resources are needed.
Date actions will be completed: / 10th August 2015
How will people who use the service(s) be affected by you not meeting this regulation until this date?
As this regulation has already been met by procedures put into place immediately following our inspection this question is no longer relevant.
Regulated activity(ies) / Regulation
- Diagnostic and screening procedures
- Family planning services
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
Safe Care and treatment
Medicines management
How the regulation was not being met:
We found that the registered person did not have effective systems in place to monitor medicines.
- Medicines kept in treatment rooms and the practice dispensary were secure but the keys to these were not.
- Standard operating procedures were not signed by all relevant staff.
Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve
- The keys to the
-practice dispensary cupboards
are kept in the key safe. The key to the key safe is kept in a secure location and the key safe is locked throughout the day.
- SOPs are now signed by all staff and will be signed by all staff on an annual basis
Who is responsible for the action? / Carol Taylor
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?
- By monitoring the management of the keys and the key safe
- The matter of SOPs has already been discussed at a Dispensary meeting and an action point to sign SOPs annually has been agreed and actioned. This will be monitored by checking.
Who is responsible? / Carol Taylor
What resources (if any) are needed to implement the change(s) and are these resources available?
No extra resources are needed.
Date actions will be completed: / 10th August 2015
How will people who use the service(s) be affected by you not meeting this regulation until this date?
As this regulation has already been met by procedures put into place immediately following our inspection this question is no longer relevant.
Completed by:
(please print name(s) in full) / Carol Taylor
Position(s): / Practice Manager
Date: / 22nd October 2015