Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Ashfield House on 17 November 2017. This inspection was to confirm that the practice had carried out their plan to make the improvements required identified in our previous inspection on 6 April 2017. This report covers our findings in relation to those requirements and any additional improvements made since our last inspection.

We carried out an announced inspection in March 2015 and the practice was rated as requires improvement. The practice was required to make improvements within six months as the safe domain had been rated inadequate. At the October 2015 inspection, the practice had made the required improvements to the safe domain. The October 2015 inspection found breaches of legal requirements relating to responsive and well-led domains and the practice was required to make improvements.

An announced comprehensive inspection was carried out on 6 April 2017 to confirm the practice had met the legal requirements in relation to the breaches in regulations identified in the October 2015 inspection. As a result, a requirement notice was issued for Regulation 17 HSCA Good governance as safe and well-led required improvement. This inspection is to follow up on the requirement notice.

The full comprehensive reports on the March 2015, October 2015 and April 2017 inspections can be found by selecting the ‘all reports’ link for Ashfield House-Annesley Woodhouse on our website at www.cqc.org.uk.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had updated their incident reporting and significant events policy to include non-clinical incidents with specific examples and definitions. Staff understood what types of incidents needed to be reported and how to do this.

• The cold chain policy had been reviewed and digital data loggers had been purchased and installed on all fridges as the second thermometer. We saw fridge temperatures were recorded daily and the data loggers were downloaded weekly.

• Patient safety alerts were reviewed actioned by the clinical pharmacist. Alerts relevant to the practice were discussed at the practice meeting and were a standard agenda item.

• Medication audits were carried out by the clinical pharmacist to check prescribing compliance and to monitor improvements to patient outcomes.

• Staff who had not received an appraisal in the last year were prioritised and completed an appraisal within four weeks.

• Prescription security was reviewed and strengthened. Blank prescription forms and printing paper scripts were stored in a locked room with key code security.

• Clinical audits were carried out based on NICE guidance and were discussed at practice meetings.

• The practice updated their complaints policy to include information on how to act upon the receipt of a verbal complaint. We looked at two complaints received in the last six months, one of which had been discussed at the practice meeting. We were unable to see evidence of complaint investigation within the records we examined. Complaints responses contained an apology, were concise and contained learning actions. They did not contain information on how to complain to the Parliamentary and Health Service Ombudsman, in line with the complaints policy.

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

The provider should:

• Ensure significant events are recorded using all available information and that the lessons learnt, actions required and by who are completed on the practice form.

• Ensure complaints are dealt with in line with the practice policy which states complaints are dealt with promptly, efficiently and courteously and are discussed and documented at the practice meetings. All responses should include information on how to complain to the Parliamentary and Health Service Ombudsman.

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 inspection in March 2015 and the practice was rated as requires improvement. The practice was required to make improvements within six months as the safe domain had been rated inadequate. The practice had made the required improvements to the safe domain at the October 2015 inspection. The announced inspection in October 2015 found breaches of legal requirements relating to responsive and well-led domains and improvements were required. The full comprehensive report on the March and October 2015 inspections can be found by selecting the ‘all reports’ link for Ashfield House - Annesley Woodhouse on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 6 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in October 2015. This report will cover all five key questions and include our findings in relation to those requirements and additional improvements made since our last inspection. We carried out an announced comprehensive inspection at Ashfield House - Annesley Woodhouse on 6 April 2017. Following the most recent inspection we found that overall the practice was still rated as requires improvement.

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

• There was a system for reporting and recording significant events.

• We found that when things went wrong with care and treatment, patients were informed of the incident as soon as reasonably practicable, received reasonable support, truthful information, a written apology and were told about any actions to improve processes to prevent the same thing happening again.

• There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. However not all incidents had been recorded and investigated as such.

• The practice had some clearly defined and embedded systems to minimise risks to patient safety.

• We observed the premises to be clean and tidy. There were cleaning schedules and monitoring systems in place.

• Blank prescription forms were not securely stored and the system to monitor their use was not tracking the prescriptions throughout the practice

• Fridges where medicines and vaccines were stored were not checked each day. We checked three fridges in the practice and found that there were times they were not checked which coincided with staff that worked in that roombeing on leave at times.

• There was a health and safety policy available.

• The practice had a fire risk assessment and carried out regular fire drills.

• The practice had adequate arrangements to respond to emergencies and major incidents.

• Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Data from the national GP patient survey showed patients rated the practice in line with others for several aspects of care.

• The practice offered extended hours on a Tuesday and Friday morning from 7am until 8am for working patients who could not attend during normal opening hours.

• The practice worked in collaboration with eight local practices to improve access for patients with pre-bookable appointments for patients Monday to Friday (6.30pm to 8pm) and Saturday (9am and 12pm). This service was accessible to all patients registered with the eight local practices. The practice had a number of policies and procedures to govern activity, but some of these were not practice specific and some needed further review, such as the significant incident policy.

• The practice had an overarching governance framework which mostly supported the delivery of the strategy and good quality care

• There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. However not all incidents had been recorded and investigated as such.

The areas where the provider must make improvement are:

• Implement effective governance arrangements to ensure appropriate systems are in place for assessing and monitoring the quality of services provided. For example, maintenance of the cold chain and review of temperature monitoring of the refrigerators used to store vaccines and security of prescriptions.

• Ensure processes for reporting and recording significant events, incidents and near misses is adhered to including non-clinical incidents.

• Ensure process is in place for the management of patient safety alerts and an audit trail of action taken following the alerts, such as audits and searches completed.

The areas where the provider should make improvement are:

• Consider adding governance agenda items to staff meetings such as safety alerts, NICE guidance and audit, to ensure that these are always shared with all staff.

• Continue to book and carry out appraisals on an annual basis.

• Implement a continuous programme of quality improvement including 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 Ashfield House - Annesley Woodhouse on 13 October 2015. Overall the practice is rated as requires improvement.

Our previous comprehensive inspection carried out in March 2015 found breaches of legal requirements (regulations) relating to the safe, effective and well led domains; and improvements were required. The overall rating from the March 2015 inspection was requires improvement and the practice was required to make improvements within six months as the safe domain had been rated inadequate.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements. The inspection carried out on 13 October 2015 found the practice had made sufficient improvements to comply with all but one regulations they were previously in breach of.

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

• There was a system in place for reporting and recording significant events although this needed to be strengthened to ensure an accurate record was kept of the action taken by staff.

• Staff understood and fulfilled their responsibilities to raise concerns and report significant events.

• Improvements had been made to the assessment and management of risks relating to the health, welfare and safety of patients. This included processes and procedures related to safeguarding children and vulnerable adults from abuse and recruitment checks.

• Action plans were in the process of being implemented to ensure identified risks were sufficiently mitigated and their management embedded.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Some staff had received appraisals; however additional appraisals had been scheduled for all other staff.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Most patients said they found it easy to make an appointment and that there was continuity of care, with urgent appointments available the same day.
• The national patient survey results showed patient outcomes were lower than the local and national averages in respect to phone access and appointments. However, steps had been taken by the practice to review and address this.
• Information about services and how to complain was available and easy to understand.
• 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.
• The practice had a number of policies and procedures to govern activity, and some of these were in the process of being reviewed.

The areas where the provider must make improvements are:

• Ensure systems and processes are operated effectively and embedded to minimise risks to people. This includes assessing, monitoring and mitigating risks as well as improving the quality of services. For example, ensure all outstanding actions related to review of policies and procedures, infection control, health and safety and staff appraisals are completed as detailed in the action plan submitted to the CQC.

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 focused inspection at Ashfield House on 17 November 2017. This inspection was to confirm that the practice had carried out their plan to make the improvements required identified in our previous inspection on 6 April 2017. This report covers our findings in relation to those requirements and any additional improvements made since our last inspection.

We carried out an announced inspection in March 2015 and the practice was rated as requires improvement. The practice was required to make improvements within six months as the safe domain had been rated inadequate. At the October 2015 inspection, the practice had made the required improvements to the safe domain. The October 2015 inspection found breaches of legal requirements relating to responsive and well-led domains and the practice was required to make improvements.

An announced comprehensive inspection was carried out on 6 April 2017 to confirm the practice had met the legal requirements in relation to the breaches in regulations identified in the October 2015 inspection. As a result, a requirement notice was issued for Regulation 17 HSCA Good governance as safe and well-led required improvement. This inspection is to follow up on the requirement notice.

The full comprehensive reports on the March 2015, October 2015 and April 2017 inspections can be found by selecting the ‘all reports’ link for Ashfield House-Annesley Woodhouse on our website at www.cqc.org.uk.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had updated their incident reporting and significant events policy to include non-clinical incidents with specific examples and definitions. Staff understood what types of incidents needed to be reported and how to do this.

• The cold chain policy had been reviewed and digital data loggers had been purchased and installed on all fridges as the second thermometer. We saw fridge temperatures were recorded daily and the data loggers were downloaded weekly.

• Patient safety alerts were reviewed actioned by the clinical pharmacist. Alerts relevant to the practice were discussed at the practice meeting and were a standard agenda item.

• Medication audits were carried out by the clinical pharmacist to check prescribing compliance and to monitor improvements to patient outcomes.

• Staff who had not received an appraisal in the last year were prioritised and completed an appraisal within four weeks.

• Prescription security was reviewed and strengthened. Blank prescription forms and printing paper scripts were stored in a locked room with key code security.

• Clinical audits were carried out based on NICE guidance and were discussed at practice meetings.

• The practice updated their complaints policy to include information on how to act upon the receipt of a verbal complaint. We looked at two complaints received in the last six months, one of which had been discussed at the practice meeting. We were unable to see evidence of complaint investigation within the records we examined. Complaints responses contained an apology, were concise and contained learning actions. They did not contain information on how to complain to the Parliamentary and Health Service Ombudsman, in line with the complaints policy.

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

The provider should:

• Ensure significant events are recorded using all available information and that the lessons learnt, actions required and by who are completed on the practice form.

• Ensure complaints are dealt with in line with the practice policy which states complaints are dealt with promptly, efficiently and courteously and are discussed and documented at the practice meetings. All responses should include information on how to complain to the Parliamentary and Health Service Ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice