CQC Report

Updated on 17th September 2015 at 8:00 am


Practice Statement following CQC Assessment



The practice underwent a CQC inspection on 16th July 2015 which examined 5 areas of General Practice:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive to people’s needs?
  • Are services well-led?

The inspection also looked at six patient population groups during the inspection:

  • Older people
  • People with long-term conditions
  • Families, children and young people
  • Working age people (including those recently retired and students)
  • People whose circumstances may make them vulnerable
  • People experiencing poor mental health (including people with dementia)


The full report can be seen at:   www.cqc.org.uk or Marine Medical Group Final Inspection Report


We are pleased that the Practice received an overall ‘GOOD’ rating.


Some areas were highlighted by the CQC report as being “Good” and include:

  • Staff knowing how to raise concerns and report incidents. Information about safety is recorded, monitored, reviewed and addressed where necessary.
  • Risks to patients are assessed and well managed.
  • Patients feel they are treated with care, respect and dignity and feel involved in decisions made regarding their own care/ treatment.
  • Information about services and the complaints procedure is easy to understand.
  • Pre-bookable early morning appointments are available two mornings a week with the GP, Practice Nurse and Healthcare Assistant.
  • The practice is well equipped to deal with patient’s needs.

In addition to this the CQC inspectors identified three areas within the safety domain which needed to be addressed and improved. These related to:

  1. Vaccine refrigerator temperature recording
  2. Regulations in relation to the Healthcare Assistant Role
  3. Handling of Blank FP10’s (prescriptions)


a) Vaccine refrigerator

The Practice worked closely with the local Screening and Immunisation Team to investigate errors in the manual recording of the Refrigerator Temperature. After a thorough investigation it was concluded that the error had been in the manual resetting of the thermometer. The refrigerator had functioned correctly and the recorded actual temperatures had always been within acceptable range. It was thus concluded that the stored vaccines were completely safe.

Nevertheless the practice has introduced several measures to improve standards by:

  1. Improving staff training by nurses carrying out annual on-line training in vaccine and immunisations including vaccine storage.
  2. Carrying out an annual risk assessment of the refrigerator to ensure a safe cold chain.
  3. 24 hour data logging devices have been purchased to keep log of all temperature changes within the refrigerator to enable any breach in temperature to be investigated immediately and ascertain if there is cause for concern.
  4. An additional refrigerator has been purchased on the advice of the investigation team to be used as a reserve.


b) Healthcare assistant

Even though the Healthcare assistant (HCA) has been fully trained to give flu vaccinations, the CQC identified that the Practice had been using Patient Group Directives (PGD’s) rather than Patient Specific Directives (PSD’S) to authorise vaccinations.

The Practice has looked at ways to overcome this but we feel that that to safely comply with vaccination regulations only our Practice Nurses will undertake vaccinations at the present time.


c) Blank prescription boxes

It was noticed during the practice’s CQC visit that although a record was kept of FP10’s (blank prescription) serial numbers when they were being given to GPs, the serial numbers were not being recorded when the boxes of prescriptions were received into the practice from the supplier. For safety reasons this system needed to be changed so that in the event of a break-in, the Practice can inform the Police and NHS Authorities of the seral numbers to enable tracking and any illegal use of the FP10’S.

The current system has been revised and now comprises of a spreadsheet which documents the serial numbers of each box and the date it was received into the practice. When the box is given to a GP the date given is recorded against the matching serial numbers along with which GP the box was given to, and the name of the member of staff who gave it.


We hope this statement addresses any concerns which may have been raised by the CQC report.

We wish to emphasise that Patient Safety is of paramount importance and we have fully addressed the weaknesses identified by the CQC assessment.