CQC PMS Inspections
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Telephone: 03000 616161
Fax: 03000 616171
www.cqc.org.uk
Your account number: 1-507418996
Our reference: INS1-528135961
Dr John Elder
C/o Ms L Allen,
Market Cross Surgery
Bourne Road
Corby Glen
Grantham
Lincolnshire
NG33 4BB
22 December 2015
Care Quality Commission
Health and Social Care Act 2008
Factual accuracy check
Location name: Market Cross Surgery
Location ID: 1-507418996
Dear Dr Elder,
Following our recent inspection of Market Cross Surgery we have drafted the inspection
report which is enclosed for your information. This report and GP letter has been sent to
the email address of your practice manager as your contact details still have the email
address of an old employee.
If you have any comments about factual inaccuracies in the report, please submit these
together as one response and send them to us by 12 January 2016.
You can record your comments in the attached factual accuracy comments log.
We would prefer you to send this information to us by email, to this address:
[email protected]. If you are unable to do so, please send it by post to the
address shown below.
Please include your account number (1-507418996) and our reference number (INS1528135961) in your letter or email as it may cause delay if you do not.
We will review your comments and amend the report if we consider it appropriate to do
so. If we do not accept your comments we will explain why.
If we do not receive any comments from you by the date shown above, we will finalise
the report and publish it on our website.
1
Your inspection report has been produced using our new approach to regulating and
inspecting. For NHS GP practices, part of the new approach will be the publication of
ratings for each location, at both key question and population group level. Ratings are
awarded on a four-point scale; ‘Outstanding’, ‘Good’; ‘Requires Improvement’, or
‘Inadequate’.
The table below shows the ratings this location has been awarded:
Safe
Effective Caring Responsive
Well-led
Overall
population
group
Older people
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
People with
long term
conditions
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Requires
Improvement
Good
Good
Good
Requires
Improvement
Requires
Improvement
Overall
domain
Requires
Improvement
Good
Good
Good
Requires
Improvement
Overall
location
Requires Improvement
Families,
children and
young people
Working age
people and
the recently
retired
People in
vulnerable
circumstances
People
experiencing
poor mental
health
We ensure a fair process for setting ratings and will be transparent in investigating any
concerns. We will explain how and when you can request a review of your ratings in the
letter we send with the final report. You can only request a review of your ratings if you
think we have not followed our published process for awarding ratings.
If you have any questions about this letter, you can contact our National Customer
Service Centre using the details below:
2
Telephone: 03000 616161
Email:
[email protected]
Write to:
CQC PMS Inspections
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Yours sincerely,
Carolyn Fairbrother
CQC Inspector
Enclosed:
 Draft report
 Factual accuracy comment log
3
Factual accuracy comments log for the draft report
Please fill in all parts of this form and return by email to:
[email protected], or by post to: CQC PMS Inspections, Citygate, Gallowgate,
Newcastle upon Tyne, NE1 4PA
Account Number:
Our reference:
Location name:
Location address:
1-507418996
INS1-528135961
Market Cross Surgery
Bourne Road, Corby Glen, Grantham, Lincolnshire,
NG33 4BB
Page
Heading
e.g. Is the
number
e.g. Pg 10 Service
Safe?
Suggested changes
with explanation
e.g. change last sentence
from 10 staff to 15 staff
Pg 3 Bullet
point 2 – 1st
paragraph
The 3 sites selected were
deemed appropriate because
of their secure locations; the
guidance produced by the DDA
regarding remote medicine
pick up points has been
followed – in particular no
scheduled or controlled drugs
can be delivered to these
points & no cash transactions
take place
Summary of
findings
Page 11
Page 16
CQC
decision CQC comments
e.g. explanation of
decision
or X
Thank you for your
feedback which we have
considered.
X
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
No risk assessments
had been carried out for
these locations.

Pg 3 Bullet
point 3 – 1st
paragraph
Page 11
Page 17
Summary of
findings
These are performed regularly
and all emergency drugs &
equipment is in full working
order. Drugs are appropriate
to a primary care setting and in
date. The protocol has been
revised and issues pertaining
to checks not always being
carried out when staff are on
leave addressed
X
The report has been
amended to say ‘three
medicine pick up points’.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspections there was
found to gaps in the
checking of emergency
4
drugs and equipment.
Pg 3 Bullet
point 4
Summary of
findings –
should make
improvements
Page 11
Mitigating risks & actions –
what exactly is meant by this?
The business continuity plan
provides the Practice with
what is required for an
extreme event – it is a
comprehensive & practical
informative document
produced following standard
examples
X
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
Within a business plan
there needs to be a risk
assessment which looks
at the areas identified in
the plan, for example,
loss of power supply,
and decide what level of
risk that would be.
Page 17
Pg 3 Bullet
point 5
Page 11
Pg 3 Bullet
point 6
Page 11
Summary of
findings –
should make
improvements
Summary of
findings –
should make
improvements
Ensure SOPs for Dispensary
include a competency section
– staff competencies are
assessed as part of our annual
DSQS submission. Discussions
already taken place that the
competencies will form part of
the appraisal process for
Dispensary staff.
Fridge temperature recordings
are and always have been
made in accordance with the
manufacturer’s instructions for
Thank you for your
feedback which we have
considered.
X
In your action plan post
inspection you identify
that a Risk
rating(mitigating risks)
will be added to the
business continuity plan.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
X
As discussed with the
dispensary manager
each standard operating
procedure requires a
section that states what
the competency of staff
should be for that
required SOP.
Thank you for your
feedback which we have
considered.
5
the various fridges; following
concerns raised about the
accuracy of built in fridge
temperature monitors
additional in fridge monitoring
USB devices have been
purchased & have been in
operation for some time
before the visit
Page 16
Pg 3 Bullet
point 7
Summary of
findings –
should make
improvements
Page 11
Page 17
Pg 3 Bullet
point 8
Pg 3 Bullet
point 9
(continued
overleaf)
Summary of
findings –
should make
improvements
Summary of
findings –
should make
improvements
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspection we saw
records that showed that
the minor operations
fridge had not been
reset on a daily basis
First aid equipment – the
practice is a provider of a
minor injury service – a full
comprehensive stock of all first
aid equipment is kept within
the treatment room; it is
unfortunate that an old kit was
found in the back of a
cupboard on the day of the
inspection – this is not in use
nor has it been. The items
within designated “out of
date” were not perishable or
sterile. Mea culpa – we should
have thrown it out
X
Minor surgery & IUCD audits
are performed quarterly for
payment & quality purposes.
They were not viewed nor
were they asked to be viewed.
The Practice was a founder site
for the RCGP/HSCIC Minor
Surgery audit – involvement in
this project was temporarily
suspended during 2015 due to
functionality issues with the
HSCIC Website
X
Notes summarisation – the
Practice has fully summarised
records for 95% of all patients
– all incoming records are
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspection out of date
contents were found to
have expired in 2009.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
I have checked the
inspection notes and we
were not shown aa
minor surgery or IUCD
audit. We were told that
the lead GP had not
completed one during
2015.
Thank you for your
feedback which we have
considered.
6
summarised as quickly as
possible - the Practice was an
early adopter of GP2GP
transfer – in addition to
reviewing all incoming
electronic notes manual
updating & checking is
performed.
There is no significant back log
of notes needing summarising
& we cannot accept this
criticism. The checking of
paper records against incoming
electronic records is a lengthy
and time consuming process
but is undertaken in a
systematic way
Pg 3 Bullet
point 10
Page 12
Pg 3 Bullet
point 12 &
Pg 5 Bullet
point 5
Summary of
Evidence of NMC registration
findings –
for all nurses was provided on
should make
the inspection day
improvements
Summary of
findings –
should make
improvements
Responsive to
needs
Page 12
Page 21
Pg 4 Bullet
point 3
Page 2
Page 3
Page 11
Safe Summary
Learning from complaints – In
addition to complaints being
discussed at practice meetings
or with individual clinicians an
annual review of complaints
meeting is held (as per old
QOF) with summary of
complaints & learning points.
Evidence of our 2014-15
complaints review was emailed to Carolyn Fairbrother
on 25.11.2015 shows wording
learning points shared with
relevant staff on front cover
sheet of review document
All clinical staff have
completed appropriate level 3
training or are booked on the
appropriate course (new
Practice nurse was already
booked on level 3 child
protection for 2016 at the time
of the inspection – her training
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspection we were told
by staff that there was a
backlog of
approximately 50 sets of
patient records going
back to January 2015.
At our feedback session
you identified that a
member of staff would
be given more hours to
ensure that the
summarisation of notes
was brought up to date.


Thank you for your
feedback which we have
considered.
The report has been
amended.
Thank you for your
feedback which we have
considered.
The report has been
amended.

Thank you for your
feedback which we have
considered.
The report has been
amended.
7
Pg 4 Bullet
point 4
Safe Summary
records are locked by her
previous NHS trust but we are
assured she has completed
level 3 adult safeguarding)
General safety issues – see P16
comments
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
Pg 5 Bullet
point 2
Pg 5
Responsive to
people’s
needs
Well Led
On reviewing the figures
quoted throughout our draft
report for the July 2015 survey
against the online GP Patient
Survey results we have found
the percentages do vary.
Please could these be
rechecked to ensure the
correct percentages are shown
in our published report
Completely contradictory
statements – High standards
are promoted & owned by
practice staff with high levels
of constructive engagement &
teams working together across
all roles yet you state there is
limited framework to support
the delivery of good quality
care. This is unacceptable &
unjustified. Elsewhere we are
complemented on audit &
outstanding levels of patient
satisfaction & results – risks
are monitored, patients
reviewed in detail at weekly &
quarterly meetings involving
multidisciplinary teams –
X
In your action plan post
inspection you identify
an estimated completion
date of 31January 2016
Thank you for your
feedback which we have
considered.
We will not amend the
report.
X
All the data on pages
2,5,11,20 and 21of the
draft report had been
rechecked against the
July 2015 national
patient survey and is all
correct.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspection and within
your action plan sent
after the inspection you
have identified that
the practice had a
8
considerable evidence of this
was provided & discussed at
length yet is not reflected in
the report.
MDT meetings utilise actual
patient computerised records
– additions & annotations are
made during meetings or
shortly after where little of
significance is decided.
limited governance
framework in place to
support the delivery of
the strategy and good
quality care. For
example, systems for
assessing and
monitoring risks and the
quality of the service
provision.
The practice completely
refutes the suggestion that we
are anything other than well
led – the practice has grown &
flourished over the past 20
years in the face of significant
competition; the list has risen
for 800 to 4300; staff turnover
is minimal, moral was high
despite the current NHS
situation and we have been
able to move to purpose built
premises at significant
personal cost to the GP
principal; the practice is an
active provider of all enhanced
services including services to
non-registered patients such as
advanced Family planning
including IUCDs & Sub dermal
implants & has historically
provided HPV vaccination &
INR services for other local
Practices who chose not to
provide for their patients; it is
a major employer in the
community & provides a vast
range of services beyond that
normally seen in primary care.
The Practice has provided the
County with a near patient
testing Enhanced service for
community DVT management
and is currently piloting a teledermoscopy service; The
practice championed the cause
of Parkinson’s disease & was
instrumental in the
establishment of the
Parkinson’s nurse service in
South Lincolnshire. The
9
Practice was instrumental in
the CCG promoting screening
for AF in line with national
guidance & the provision of a
cardiology up-skilling course
for local GPs.
In addition, we also have been
able to provide in house
Physiotherapy & Ultrasound
services
We will accept that formal
appraisal had not occurred for
all staff in the past 12 months
yet despite this comprehensive
additional postgraduate
training & career development
has been undertaken by all
clinical staff.
Pg 7 Older
people
Summary of
findings
Requires improvement yet all
points are good or excellent
except for “safety & Well led”
which we do not accept
X
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because on the
inspection day and in
this FAC you have
agreed that this is
correct..
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain -
Page 7
Long-term
Conditions
Summary of
findings
Requires improvement yet all
points are way above local or
national levels – should be
Outstanding
X
‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
Thank you for your
feedback which we have
considered.
We will not amend the
10
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain -
Pg 8
Families,
children &
young
people
Pg 8
Working
age people
Summary of
findings
Summary of
findings
All points were good with
above national average figures
& high levels of immunisation
uptake & examples of
multidisciplinary working with
midwives & Health visitors yet
again graded as Requires
improvement
All points extremely positive
yet gain graded as requiring
improvement
X
‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain -
X
‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain ‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
11
Pg 9
Vulnerable
groups
Summary of
findings
Again glowing reports yet
rated as requiring
improvement
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain -
Pg 9 Poor
mental
health
Pg 11 Bullet
point 1
Summary of
findings
Areas for
improvement
- Must take
action
As before significantly above
average statistics & reports –
not mentioned in the report
the Practice is involved with
the local dementia service &
plans to provide facilities for
an in house CPN run dementia
assessment service in
conjunction with the CCG – yet
again “requires improvement”
We accept that significant
event meetings have been less
frequent in the past year than
previously however evidence
was provided of a true
significant event for which a
separate meeting was held,
independent advisor invited to
attend & from which a revision
to a dispensary SOP was
derived.
Significant event meetings
need to be significant
X
‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
paragraph in this section
is correct. Due to the
overall rating being
Requires Improvement
along with Safe and
Well-led domain -
X
‘The concerns which led
to these ratings apply to
everyone using the
practice, including this
population group.’
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
X
The practice did not
12
otherwise they merge into
normal practice business & the
“significance” is lost; all staff
are & have been involved in
the past & learning is cascaded
where appropriate both
internally & externally. We
have been regular contributors
to clinical governance reports
particularly relating to poor
INR management in hospital
and on discharge.
All clinical staff are trained to
level 3 Adult safeguarding; The
new practice nurse has been
enrolled (before CQC visit) on
level 3 child protection during
2016. All clinicians are aware
of their individual
responsibility to maintain level
3 training & evidence of this
was provided on the inspection
day
These are all repeated earlier
in the document
Pg 11 Bullet
point 2
Areas for
improvement
– Must take
action
Pages 11 &
12
Summary of
findings
Pg 13
Paragraph
3
Background to Practice Manager is not a
MCS Partner
Pg 13
Paragraph 3
Page 13
Paragraph 3
Background to We have 3 Practice Nurses
MCS
Background to We have 5 Dispensers
MCS
Page 14
Detailed
penultimate Findings
paragraph
line 2
Page 15
Bullet point
Safe
You spoke to 3 Practices
Nurses on the inspection day
Please provide us with details
of the two significant events
have a system in place
to ensure significant
events and near misses
were recorded correctly,
investigated and any
learning cascaded to
staff

As page 7 of this FAC
this report has been
amended
See comments in early
boxes

Thank you for your
feedback which we have
considered.

The report has been
amended.
Thank you for your
feedback which we have
considered.

The report has been
amended.
Thank you for your
feedback which we have
considered.

The report has been
amended.
Thank you for your
feedback which we have
considered.
X
The report has been
amended.
Thank you for your
feedback which we have
13
1
which were not recorded on
the correct form
considered.
We will not amend bullet
point 2 of the report
because the record of
our inspection shows
that this paragraph is
factually accurate.
On checking the
inspection notes there
were a number of
incidents not on the
correct form:for example,
Sample given wrong
name on label trace –
system down
Patient given path links
form with wrong patient
name on it.
Page 15
Bullet point
2
Safe - our
findings
Significant events – see above
but also statement is untrue –
A full annual compilation of
significant events had not been
prepared since 2014 – these
are undertaken annually
previously for submission with
QOF but latterly as part of GP
appraisal & annual returns to
NHSE; therefore the 2015
summary of SE meetings is
now due to be produced – SE
meeting had taken place in
spring of 2015 & another
meeting was due in the late
summer but had been delayed.
If there were examples of
incidents of a significant level
that were identified to you but
had not been reported as such
then please expand & clarify.
Not all events are discussed in
a significant event meeting –
particularly if they are of a
disciplinary nature. Your
clarification of this would be
appreciated as it was not
raised at the time of the visit.

Thank you for your
feedback which we have
considered.
The report has been
amended.
The sentence .’During
our inspection, we
requested details
of annual reviews of
significant events. We
were told that these had
not been carried out
since 2014’ has been
removed.
And we have added ‘We
found that the practice
had not undertaken an
exercise to identify any
themes or trends’
14
Page 16
Bullet point
6
Page 16
Bullet point
8
Page 16
Bullet point
9
Safe
Safe
Safe
Recruitment policies – all
appropriate registration &
qualification checks were in
place for employed
professionals including DBS
checks where appropriate.
The Practice will consider
moving to DBS checks on all
staff (including longstanding
members of staff who have
been employed with the
practice for a number of years)
given their multiple roles
within the organisation, The
current regulations are
adhered to
X
Thank you for your
feedback which we have
considered.
We will not amend bullet
point 6 of the report
because the record of
our inspection shows
that this paragraph is
factually accurate.
On checking the
inspection notes gaps
were found in the
recruitment checks prior
to employment.
H&S Risk Assessment June
2015 – confirmation by e-mail
to Carolyn Fairbrother post
inspection 10.12.15 confirming
actions were ongoing; as
demonstrated with post
inspection evidence an action
plan for anything outstanding
is in place demonstrating our
commitment to ongoing H&S
improvements and monitoring
X
We have an arrangement in
place with Churches Fire for
regular checks on our fire
panel, emergency lighting and
fire extinguishers. There is a
log book and folder in the
Practice Managers office
where this information is
recorded. A member of our
Reception Team tests the fire
alarm and records in the book
contained in the above folder.
Although fire drills &
evacuations have historically
been recorded in the surgery
day book – these are now
X
In your action plan post
inspection you identify
that a recruitment
checklist will be added
to the policy for all new
staff with immediate
effect.
Thank you for your
feedback which we have
considered.
We will not amend bullet
point 8 of the report
because the record of
our inspection shows
that this paragraph is
factually accurate.
Thank you for your
feedback which we have
considered.
We will not amend bullet
point 9 in regard to the
fire risk assessment
because the record of
our inspection shows
that this paragraph is
factually accurate
In your action plan post
15
Page 16
Bullet point
11
Page 16
Bullet point
13
Safe
Safe
recorded in the above log
book. The actions for the 2012
fire risk assessment were
carried out but there has not
been a further risk assessment
to date. In addition to the
checks already being carried
out by Churches an Annual Fire
Risk Assessment will take place
going forward; Louise Allen &
Sarah Rutherford are booked
on Fire Warden Training in Feb
2016
It is incorrect that none of the
actions from the legionella
action plan had been carried
out at the time of the
inspection. Regular water
temperature checks (monthly)
take place and the log was
seen on the inspection day.
Flushing of identified
infrequently used taps where
appropriate would take place
and be logged; in fact the taps
identified in the last report are
in frequent use and this is one
of many inaccuracies within
the Legionella report. Flow
temperature monitors are
already fitted to the pipes
providing hot water
distribution & all pipe work is
appropriately colour coded
with directional markings. The
taps in consulting & clinical
rooms are a mixer type with
temperature limiting valves
not as described in the report.
We are concerned that the
Legionella report is factually
incorrect & we will be using an
alternative engineering firm
for the next report. There are
no key outstanding areas of
work
All staff undergo annual basic
life support training
inspection you identify
that you were uncertain
if the action points were
completed from the two
previous reports.
X
Thank you for your
feedback which we have
considered.
We will not amend bullet
point 11 in regard to the
legionella risk
assessment because
the record of our
inspection shows that
this paragraph is
factually accurate
In your action plan post
inspection you identify
that action points to be
completed by 31/3/16..

Thank you for your
feedback which we have
considered.
The report has been
amended.
16
Page 17
Bullet point
1
Safe
Post inspection evidence in the
form of letter was sent to
Carolyn Fairbrother justifying
why we do not have paediatric
defibrillator pads
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
A letter was received
post inspection. Further
email sent by inspector
asked the practice to
clarify if a risk
assessment had been
carried out in light of the
decision made re
paediatric defibrillator
pads. No further
information was
received.
Page 17
Bullet point
3
Safe
The protocol stated weekly
although this had been relaxed
to fortnightly. There were still
omissions & this has been
immediately addressed &
designated nurse procedures
strengthened including
deputies & a protocol refresh.
All emergency drugs are
recorded on an excel
spreadsheet with their expiry
dates linked to colour coding
(conditional formatting – turn
red when expired)
Drugs are re-ordered in
advance of expiry EXCEPT
when they are unavailable in
which case they are retained
within the extension beyond
expiry date as suggested by
manufacturer (emergency
injectable drugs are often
unavailable and drug shelf life
has to be extended)
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
On the day of the
inspections there was
found to gaps in the
checking of emergency
drugs and equipment.
In your action plan you
have documented that
the practice will ensure
system in place for
emergency equipment
checks in the absence
of Christine Day. With
immediate effect.
17
Page 17
Bullet point
5
Page 19
Bullet point
2
Safe
Effective
Business continuity plan – all
key risks identified; no
recommendation or
requirement for risks to be
“rated” – the document is a
working document for use in
times of crisis
Please provide details of staff
members who did not have an
appraisal record on their
personnel file
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
Within a business plan
there needs to be a risk
assessment which looks
at the areas identified in
the plan, for example,
loss of power supply,
and decide what level of
risk that would be.
X
In your action plan post
inspection you identify
that a Risk
rating(mitigating risks)
will be added to the
business continuity plan.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
For example:Kirstie Simmons
Christine Day
Page 19
Bullet point
3
Effective
Please provide details of staff
who were missing from the
training matrix
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
18
accurate.
For example:Dispensary Staff
Page 19
Bullet point
4
Effective
Training all staff completed
the 2 day mandatory
Pathway training including
BLS & child protection yet
elsewhere you suggest this
is not the case. All staff
completed this training for
the past 2 years.

Thank you for your
feedback which we have
considered.
Page 16 of the report
has been amended.
Pages 20 &
21
Caring
In comparison with reports of
practices elsewhere in the UK
these results should be graded
as outstanding
X
Page 21
final Bullet
point
Responsive
If there were themes or trends
shown in complaints received
these would be highlighted,
discussed and highlighted at
our annual complaints meeting
X
Thank you for your
feedback which has
been noted. However
the rating remains the
same.
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
There was no evidence
on the day of the
inspection to suggest
themes and trends were
considered.
Page 22
Well Led
See P5 above – your comments
however “clear staff structure,
clear leadership structure in
place, open culture within the
practice, confident to raise
issues, supported, respected
valued; all involved with
development & opportunities
to improve the service
provided
X
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that the
paragraphs on page 5
and page 22 are
factually accurate.
On the day of the
inspection and within
19
your action plan sent
after the inspection you
have identified that
the practice had a
limited governance
framework in place to
support the delivery of
the strategy and good
quality care. For
example, systems for
assessing and
monitoring risks and the
quality of the service
provision.
Page 22
Bullet point
7
Governance
Louise Allen completed Level 3
H&S Management Course in
July 2015 which will enable
further progression of risk
assessments required. This
investment also demonstrates
that the practice is committed
to our H&S obligations. H&S
assessments including
Legionella & Fire – see notes
above but Legionella all points
addressed & compliant – Fire
risk assessment all points
addressed & compliant from
2012 – regular fire system
inspections & reporting
(Include additional rows if required)
X
Completed by (name(s))
Dr John Elder & Louise Allen
Position(s)
Senior Partner & Practice Manager
Date
08.01.2016
Thank you for your
feedback which we have
considered.
We will not amend the
report because the
record of our inspection
shows that this
paragraph is factually
accurate.
In your action plan post
inspection you identify
an estimated completion
date of 31January 2016.
20