Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boughton Surgery on 7 December 2016. This inspection was a follow up to our previous comprehensive inspections at the practice in January 2015 and May 2016 where breaches of regulation had been identified. The overall rating of the practice following the May 2016 inspection was Inadequate and the practice was placed into special measures for a period of six months.

Following our inspection in May 2016 we issued a warning notice to the provider requiring improvements in in relation to good governance. A visit was undertaken on 12 August 2016 to ensure that the specific improvements had been made.

At our inspection on 7 December 2016 we found that the practice had improved. The ratings for the practice have been updated to reflect our recent findings. The practice is rated as good for providing safe, effective, caring, responsive and well led services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• The practice had implemented new systems and processes to ensure that risks to patients were assessed and well managed. For example, comprehensive recruitment checks were now in place for new members of staff.
• The practice was proactive in safeguarding children, and had implemented a protocol for the monitoring of children who did not attend hospital appointments.
• Extensive work had been undertaken to ensure that there was an effective system in place to support patients who were prescribed drugs that required monitoring. Furthermore, a protocol had been developed to ensure that reviews of safety updates from the Medicines and Healthcare Products Regulatory Agency (MHRA) were undertaken.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Feedback from patients about their care was positive. Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had analysed patient feedback and made changes to the appointment system to ensure that patients had improved access to appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure in place and staff felt well supported by the GP partners.
• Policies and procedures had been reviewed and updated to the requirements of the practice.
• The provider was aware of and complied with the requirements of the duty of candour.

I confirm that this practice has improved sufficiently to be rated good overall. This practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This was the third inspection we had carried out at Boughton Surgery. The practice had previously been inspected in January 2015 and May 2016.On 31 May 2016, we carried out a comprehensive inspection of Boughton Surgery.The inspection report at that time rated the practice as inadequate overall and the practice was placed into special measures. You can find the report for the comprehensive inspection on the CQC website (www.cqc.org.uk).

Following the comprehensive inspection we issued a warning notice to the practice because there were immediate risks to patients that required urgent attention by the practice in relation to good governance.As a result of the findings on the day of the inspection the practice was issued with enforcement actions for regulation 17.

During the period from May 2016 to our inspection in August 2016, the practice had experienced several major challenges in addressing the issues identified. For example, the practice was victim to an incendiary bomb incident and a lorry damaged part of the building.

A large number of the improvements needed as identified in the report of May 2016 had been made, however, some of these needed to be improved further.

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

• We found that improvements had been made to the process for following up safety alerts.

• Although the practice had not undertaken any minor surgery we saw that the consent form and process had been put in place.

• The practice had implemented robust medication review systems to monitor patients who were taking medicines that required monitoring.

• Significant improvements had been made to the practice policies and procedures; however, further improvement was needed to ensure that these were cascaded and used by staff.

• Significant event reporting and learning shared had been improved; there was scope for this to be further improved.

• The personnel files we viewed on the day of inspection did not all contain all the necessary information to ensure that the staff the practice employed were suitable.

• Management’s oversight of the training of staff was not robust.

• We found the systems and management in place for assessing; ; monitoring and mitigating the risks related to the control of substances hazardous to health (COSHH) were robust.

• We reviewed the systems in place for safeguarding children and found that they had been improved. A protocol was in place to follow up children who had not attended hospital appointments.

Action the service MUST take to improve

• Ensure that the appropriate recruitment checks are undertaken.

• Ensure that all staff have received the appropriate training and assessments required to undertake the tasks delegated to them.

Action the service SHOULD take to improve

• Embed effective processes for policies and procedures into the culture of the practice

The practice continues to operate within the special measures applied by the CQC and will continue to do so for a total of six months from the publication of the report dated 31 May 2016. After this time, CQC will revisit and re-inspect Boughton Surgery and will amend our judgements and ratings in accordance with our findings at that time.

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 follow up inspection at Boughton Surgery on 31 May 2016. The overall rating for this practice is inadequate.

We had identified a number of shortfalls at our previous inspection in January 2015 and found that the practice required improvement in the safe and well-led domains. We issued two requirement notices under the Health and Social Care Act 2014 as a result.

During this follow up inspection, we found that the practice had taken action to address a number of the shortfalls noted previously. For example,

• Improvements had been achieved in addressing the infection control concerns identified at the initial comprehensive inspection.
• The practice had taken reasonable steps to ensure the safe management of medicines.
• The practice had developed a process for monitoring the collection of dispensed prescriptions at external allocations.
• There was a sufficient supply of emergency equipment available, with an effective monitoring system in place.
• The safety of medicines stored within the dispensary had improved and medicines were organised on shelving units rather than on the floor, which reduced trip hazards within the small dispensary.

However, we found that there were issues that the provider had failed to address since the previous inspection in January 2015. Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, we did not see evidence of appropriate recruitment checks on staff undertaken prior to their employment, or evidence of appropriate induction and relevant training.
• The practice did not have an effective system in place for identifying and managing risks to patients and staff. For example, there was no health and safety risk assessment in place. We were told that staff were briefed on health and safety during their induction periods, but we saw no evidence of further training.
• The system in place for safeguarding children was not sufficiently robust. For example, there was no protocol in place to follow up children who had not attended hospital appointments.
• Policies and procedures were not personalised to the practice and some required updating. We found that staff did not consistently follow the generic policies in place. There was no robust system in place to verify whether staff had seen and read a policy or update.
• The practice had a system in place for receiving and cascading patient safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA). However, data showed that there was no rigorous protocol in place to ensure that reviews of safety updates from the MHRA were undertaken.
• There was an inconsistent approach to receiving written consent prior to minor surgical procedures being carried out on site.
• Data showed that the practice did not have robust medication review systems in place to support patients who take drugs that require monitoring.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff, including locums.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure that patients who are prescribed medicines that require specific monitoring are reviewed in line with national prescribing guidance.
• Risk assess the need for staff who chaperone to have a disclosure and barring check.
• Ensure that written consent is consistently recorded prior to minor surgical procedures being carried out on site.
• Implement a protocol for reviewing children who do not attend hospital appointments.
• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

The areas where the provider should make improvement are:

• Ensure that patient safety updates from the MHRA are reviewed and actioned in a timely manner.
• Improve the system for identifying patients who are carers.
• Ensure that staff receive appraisals in a timely manner.
• Risk assess the practice environment to ensure its safety for patients and staff with a disability.

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.

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 Boughton Surgery on 7 December 2016. This inspection was a follow up to our previous comprehensive inspections at the practice in January 2015 and May 2016 where breaches of regulation had been identified. The overall rating of the practice following the May 2016 inspection was Inadequate and the practice was placed into special measures for a period of six months.

Following our inspection in May 2016 we issued a warning notice to the provider requiring improvements in in relation to good governance. A visit was undertaken on 12 August 2016 to ensure that the specific improvements had been made.

At our inspection on 7 December 2016 we found that the practice had improved. The ratings for the practice have been updated to reflect our recent findings. The practice is rated as good for providing safe, effective, caring, responsive and well led services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• The practice had implemented new systems and processes to ensure that risks to patients were assessed and well managed. For example, comprehensive recruitment checks were now in place for new members of staff.
• The practice was proactive in safeguarding children, and had implemented a protocol for the monitoring of children who did not attend hospital appointments.
• Extensive work had been undertaken to ensure that there was an effective system in place to support patients who were prescribed drugs that required monitoring. Furthermore, a protocol had been developed to ensure that reviews of safety updates from the Medicines and Healthcare Products Regulatory Agency (MHRA) were undertaken.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Feedback from patients about their care was positive. Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had analysed patient feedback and made changes to the appointment system to ensure that patients had improved access to appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure in place and staff felt well supported by the GP partners.
• Policies and procedures had been reviewed and updated to the requirements of the practice.
• The provider was aware of and complied with the requirements of the duty of candour.

I confirm that this practice has improved sufficiently to be rated good overall. This practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice