We previously carried out an announced comprehensive inspection at All Saints Surgery on 15 January and 23 January 2019 as part of our inspection programme. The practice was rated as inadequate in safe and well led and rated as requires improvement in effective, caring and responsive. This meant that the practice was rated as inadequate overall, placed in special measures and warning notices in relation to safe care and treatment and good governance were issued. The full comprehensive report on the January 2019 inspection can be found by selecting the ‘all reports’ link for All Saints Surgery on our website at www.cqc.org.uk.

We carried out an announced focused inspection at All Saints Surgery on 17 April 2019 to ensure that the issues identified in the warning notices had been addressed.

This report only covers our findings in relation to the warning notices.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected.

• information from our ongoing monitoring of data about services.

• information from the provider, patients and other organisations.

We found that:

• A system was in place for the security and management of blank prescription forms with serial number logs maintained.
• Medicines in treatment rooms were stored securely and were accessible in the event of an emergency. A portable carrier for a larger sized oxygen cylinder was in place and staff were in receipt of training in its use. A risk assessment with a clear rationale was in place for the one emergency medicine not held by the practice.
• A reduced number of patient medicine reviews were overdue monitoring and assessment for example patients who had not been in receipt of a medicine review in a 12-month period had reduced from 1,444 to 621 patients. Those patients overdue a medicine review were being invited to attend.
• The majority of recent secondary care letters that contained information provided to the practice of medicines monitored and prescribed in secondary care had been recorded within the patient record. This had reduced the potential risk of a GP prescribing a medicine contra indicated for concurrent use with the medicines prescribed in secondary care and therefore a reduced risk to patient's safe care and treatment.
• The system employed by the practice regarding letters and repeat medicines had been subject to a review and no longer relied upon non-clinical staff documenting GP findings within the clinical record with a potential risk of omission or misinterpretation.
• The provider had taken appropriate action to reduce the risk to patients by completing risk assessments including an assessment and remedial action for the corded window blinds.
• There was evidence of the cleaners Control of Substances Hazardous to Health Regulations (COSHH) risk assessments, training and cleaning product data sheets.
• An infection prevention and control (IPC) audit had been conducted with a clear action plan with dates for review and monitoring in place. There was management oversight in place to ensure that all staff had been in receipt of appropriate IPC training.
• Improvements had been made to the systems, processes and practice that helped to keep patients safe and safeguarded from abuse. The system included monitoring of children who did not attend their appointment following referral to secondary care. Staff were up to date with adult and children's safeguarding training and the policy in place reflected current practice updates including modern slavery.
• The provider had instigated a system which enabled oversight on staff qualifications, competence, skills and experience.
• We saw that a system had been implemented which included a regular meeting agenda item of ensuring staff were up to date with best practice guidelines including the National Institute for Clinical Excellence (NICE) guidelines. These included guidelines in Chronic obstructive pulmonary disease (COPD).

• Antibiotic prescribing for Amoxicillin in children aged one to five and five to 18 years old was in line with best practice guidelines. The provider had implemented the monitoring prescribing of Amoxicillin in children and had therefore reduced the risk of reoccurrence with clear governance arrangements in place.
• The provider had instigated a system which enabled clinical oversight on patients within the pre-diabetic range in order that they could be provided with lifestyle advise or a second blood test monitoring appointment.
• The provider had instigated a system which enabled clinical oversight on patients with gestational diabetes, in order that they were followed up in respect of a post-partum three month follow up blood test within a 15-month period.
• We saw that a system had been implemented which included patients having had a removal of their spleen being offered precautionary antibiotics and in receipt of a pneumovax (a particular vaccination). Where there was informed decent this was recorded within the patients’ clinical record.
• There had been improvements made in the setting up of systems and processes to ensure compliance with requirements to demonstrate good governance.
• The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions had improved and were being managed.
• A root cause analysis process had been put in place in order that the provider could conduct a thorough investigation and extract significant learning from safety incidents.
• The practice had started to record informal comments and complaints received.
• In the staff records reviewed which included a new staff member we saw that recruitment procedures had operated effectively, and records maintained.
• The provider had implemented a systematic approach for areas such as: oversight of records of skills, qualifications and training for all staff, in the follow up of children's non-attendance at secondary care appointments and in the approach to updating and monitoring policies and procedures.
• We found that the patient safety and medicine alerts patient searches were completed and up to date.

At this inspection, we found that the provider had satisfactorily addressed the issues identified in the warning notice although some medicine reviews remained in the process of being completed but there was a schedule for completion in place.

We will follow up on these issues at our next inspection.

• A number of patient medicine reviews remain overdue monitoring and assessment
• Discussions between the practice and other health and social care professionals such as health visitors to support and protect adults and children at risk of significant harm took place and were no recorded however meetings had although booked had yet to take place.
• A documented workforce and succession plan and an updated business continuity plan.

Details of our findings and the supporting evidence are set out in the evidence table.

Letter from the Chief Inspector of General Practice

We inspected this service on 6 October 2014 as part of our new comprehensive inspection programme. This provider had not been inspected before.

The overall rating for this service is good. We found the practice to be good in the safe, responsive caring and well-led domains and requires improvement in the effective domain. We found the practice provided good care to older people, people with long term conditions, people in vulnerable circumstances, families, children and young people, working age people and people experiencing poor mental health.

. Our key findings were as follows:

• Patients were kept safe because there were arrangements in place for staff to report and learn from key safety risks. The practice had a system in place for reporting, recording and monitoring significant events over time.
• The practice was responsive to the differing needs of its patient population. It had taken particular steps to support its large number of diabetic patients.
• Evidence we reviewed demonstrated that most patients were satisfied with how they were treated and that this was with compassion, dignity and respect.

We saw one area of outstanding practice:

The practice had adapted standard dementia memory tests for use with its Asian population. They had done this by including familiar Asian names and references in the test.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Ensure that audit cycles are completed.
• Improve its recruitment process to ensure that pre employment checks are completed in a timely way and that a robust audit trail is created.
• Update the information it holds about children who are known to be at risk.
• Review the emergency equipment and drugs it holds in the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at All Saints Surgery on 15 January and 23 January 2019. The announced inspection was part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected
• Information from our ongoing monitoring of data about services and
• Information from the provider, patients, the public and other organisations

We have rated this practice as Inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The management of safety systems was not effective particularly in relation to safeguarding, staff training and employment checks.
• The practice did not have appropriate systems in place for the safe management of medicines. Risks associated with blank printer prescription stationery security and management had not been fully considered.
• There were a significant number of patient medicine reviews overdue monitoring and assessment.
• Some staff had not been in receipt of all training appropriate for their role according to the practice’s policy and protocols.
• The systems, processes and practice that helped to keep patients safe and safeguarded from abuse were insufficient. The system in place at the practice had not always ensured that all children who did not attend their appointment following referral to secondary care were appropriately monitored and followed up. There were gaps in staff safeguarding training.
• Infection Prevention and Control training and processes had not been adequately applied.
• Some staff recruitment checks did not meet legal requirements.
• The analysis and responses to Medicines and Healthcare products Regulatory Agency (MHRA) alerts were not consistently applied.

We rated the practice as inadequate for providing well-led services because:

• There were gaps in the practice’s governance systems and processes and the overall governance arrangements were ineffective.
• The practice had not developed a sustainable practice business plan or strategy.
• There was a lack of oversight of the maintenance of accurate records of skills, qualifications and training for staff.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation. When incidents happened, the practice investigated but there was an absence of fully documented and embedded learning from events.
• The practice did not document informal comments and complaints and therefore trend analysis and learning could not be derived from these incidents.

We rated the practice as requires improvement for providing effective services because:

• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• We found specific instances where care and treatment had not been provided in accordance with best practice guidelines.

We rated the practice as requires improvement for providing a responsive service because:

• Most patients found the appointment system easy to use and reported they were able to access care when they needed it.
• Records we looked at confirmed there were gaps in process and risks had not been mitigated by following up some patients who had attended secondary care.
• The complaint policy and procedures were in line with recognised guidance. The practice did not document informal comments and complaints and therefore trend analysis and learning could not be derived from these incidents.

These areas affected all population groups so we rated all population groups as requires improvement with the exception of working age people which was rated inadequate.

We rated the practice as requires improvement for providing caring services because:

• Staff involved and treated patients with compassion, kindness, dignity and respect and involved them in decisions about their care.
• The National GP survey findings had been analysed however patients were less positive than the local CCG and England averages in being treated with care and concern and their confidence and trust in the healthcare professional they saw or spoke to.
• Fifty registered patients were electronically coded as being a carer which represented 0.6% of the practice population.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure the proper and safe management of medicines.
• Ensure that care and treatment is provided in a safe way.
• Recruitment procedures must operate effectively to ensure that all the documents specified in Schedule 3 were available for each person employed in the carrying out of regulated activities.
• Ensure the practice premises have appropriate documented health and safety and security risk assessments in place.
• Ensure there are effective systems, processes and practice that help to keep patients safe and safeguarded from abuse.
• Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
• Ensure staff follow best practice guidelines including the National Institute for Clinical Excellence (NICE) guidelines.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice