Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall.

The practice had been rated as Good overall at the previous inspection carried out on 19 January 2016.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Good

As part of our inspection process we also look at the quality of care for specific population groups. The issues identified as requiring improvement overall affected all patients. In addition the provision of effective services for people with long-term conditions was also rated as requiring improvement. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those retired and students) – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Ash Grove Medical Centre and Whitleybridge branch surgery on 6 December 2017. The inspection was carried out as part of our inspection programme and was also used to follow up areas where the provider had been informed previously that they should make improvement.

At this inspection we found:

• The practice had clear systems and processes in place to manage risk so that safety incidents were less likely to happen. When incidents did happen we saw that these were investigated by the practice and that processes were revised and improved to prevent a recurrence.

• The practice had experienced a high turnover of staff over a period of time and this had reduced their capacity to deliver services. The practice had actively sought to recruit additional staff and had implemented new processes to redress this.

• Patients reported difficulty in contacting the practice and accessing services. In addition patient satisfaction in relation to their involvement in decisions about their care and treatment were significantly below local and national averages.

• We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

• The practice was actively involved in health improvement activity, and took part in a number of local and national improvement initiatives. For example the practice worked with a local NHS Trust who provided a telemedicine service to two local nursing homes.

• The practice provided additional services for those with mental health needs and dementia. For example the practice had received accreditation for both its work to support dementia patients and for learning disability patients.

The areas where the provider should make improvements are:

• Improve the identification of carers to enable this group of patients to access the care and support they require.

• Review and improve the systems in place so that reviews of patients are completed in accordance with their care and treatment requirements.

• Review areas of poor patient satisfaction with the services provided and take steps to improve satisfaction in these areas. This should include telephone and appointment access and patient’s feeling involved in planning and making decisions about their care.

• Review and risk assess the decisions made with regards to choosing not to stock certain emergency medicines in line with recognised guidance.

• Review and improve quality improvement activity within the practice, including the effective use of clinical audit.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ash Grove Medical Centre on 19 January 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice :

• The practice held awareness raising events for patients and their families covering subjects such as alcohol consumption by the isolated elderly and weaning for babies.

     We saw one area where the provider should make improvement:

• The practice needed to hold regular fire drills and fire tests during periods of time when the majority of practice staff are present to ensure that they are familiar with the fire evacuation process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We saw that steps had been taken to encourage patient feedback as the practice had an established patient reference group and a comments and suggestions box located in the entrance.

We spoke with two members of the patient reference group who were able to give examples of the changes that had been made to the service as a result of feedback.

The patients we spoke with happy with the care and treatment they received. Comments included;

“I’ve been ill for several weeks and the practice has been brilliant.”

“The practice have looked after me very well over the years and I have no complaints.”

There was a nominated safeguarding lead within the practice. Staff were able to outline the different types of abuse that people may be at risk of and explain what signs they would look for to indicate that a person may be suffering from abuse.

The practice had a recruitment policy in place and two of the staff files we reviewed contained all relevant checks. One of the files we looked at did not contain references. We discussed this with the provider at the time of our inspection and were assured that references would be obtained for all future roles.

The practice had a complaints procedure in place and had taken steps to ensure that patients were aware of this process.

This practice is rated as Requires Improvement overall. At the last inspection in December 2017 we rated the practice as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

In addition, we found all population groups to be Requires Improvement.

We carried out an announced comprehensive inspection at Ash Grove Medical Centre and the branch surgery at Whitleybridge on 18 January 2019. The inspection was carried out due to the provider receiving a rating of Requires Improvement for the last inspection carried out in December 2017. The practice was rated as Requires Improvement at this latest inspection because:

• Staff had not all received recent safeguarding training appropriate to their role.
• The risk assessment for the storage and handling of hazardous substances lacked detail.
• There was no evidence that actions needed in response to the last fire risk assessment had been fully actioned.
• Window blind cords in the branch surgery were long and posed the risk of entrapment and injury.
• Staff tasked with the monitoring of refrigerator monitoring at the branch had limited knowledge of operating temperatures and key trigger temperatures.
• Patient satisfaction with appointment access was mixed and there was limited assurance that improvements in access had been fully embedded.

In addition, it was seen that 2017/18 performance in relation to the provision of effective services for people with long-term conditions showed areas of low performance. Whilst we saw unverified interim data which showed some improvement in 2018/19 this improvement needed to be continued.

This rating meant all population groups were rated as Requires Improvement.

At this inspection we found:

• The practice did not have clear systems in place to fully manage risk.
• The practice had taken action to tackle areas highlighted as requiring improvement at the last inspection carried out in December 2017. This included increasing clinical capacity and increasing the numbers of carers identified from the patient population. We saw that improvement activities were effectively planned and that performance was closely monitored.
• We saw that there were areas of low performance with regard to long-term conditions and mental health in 2017/18. We saw unverified data from 2018/19 which indicated an improvement in performance, although that in relation to long-term conditions needed to be sustained.
• The practice had some areas of low patient satisfaction in relation to appointment access and consultations reported via the national GP survey (January to March 2018). The practice had since this survey instituted a number of changes to both increase access and clinical capacity. Recent data showed an improvement in patient satisfaction, however this needed to be embedded.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice was actively involved in health improvement activity, and took part in a number of local and national improvement initiatives.

The areas where the provider should make improvements are:

• Continue to review and improve the systems in place so that reviews of patients with long-term conditions are completed in accordance with their care and treatment requirements.
• Review the provision of safeguarding training so that all revelant staff receive the necessary training.
• Review the assessment of hazardous substances handled or used within the practice to ensure that it is comprehensive.
• Review the fire risk assessment for the branch surgery to ensure areas raised had been actioned. .
• Survey all public areas to give assurance that all window blind cords are secured at an appropriate length and do not pose a risk of entrapment or entanglement.
• Review and improve the knowledge of staff tasked with monitoring duties in respect of refrigerator storage temperatures.
• Review and improve processes concerning the transportation of vaccines and medicines which required temperature control.
• Review and continue to monitor two week wait cancer referral performance.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.