Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Brace Street Health Centre on 7 March 2017. The overall rating for the practice was good with requires improvement for providing safe services. We found one breach of legal requirement and as a result we issued a requirement notice in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment

The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Brace Street Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 23 November 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 on 7 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The safe domain is now rated as good and overall the practice remains rated as good.

Our key findings were as follows:

• The practice had improved the processes in place for handling repeat prescriptions which included the review of high risk medicines. We saw that appropriate monitoring of patients had taken place prior to prescriptions being issued.
• The Patient Group Directions (PGDs) adopted by the practice to allow nurses to administer medicines in line with legislation had been signed by an appropriate person.
• Although a system had been introduced to monitor the use of prescription stationery, the records did not include the serial numbers of prescriptions on receipt and when they were distributed through the practice. The practice rectified this issue during the inspection.
• The practice had reviewed and increased the range of emergency medicines held at the practice.
• The practice had reviewed and discussed the results from the national GP survey published in July 2017 during a team meeting in October 2017. The practice acknowledged that the results reflected the staffing situation at the time the survey was carried out (January to March 2017), when there was only one permanent GP being supported by locum GPs. Action taken included adding call waiting to the telephone system, aiming to answer the telephone within four rings, and encouraging patients to book double appointments when they had more than one issue to discuss to reduce delays in appointment times. The practice also promoted the use of on line booking and had increased the number of patients signed up for on line access to 14% with a target of 20% by the end of March 2018.
• The practice had taken a more proactive approach to identifying and supporting carers. The number of carers identified had increased from 16 to 32 (1% of the patient list), and 15 of these patients had been offered an assessment. The new patient registration form asked if the patient was also a carer. Patients who identified themselves as carers were asked to provide additional information and were given the contact details for the carers association. They were also asked if they wished to be referred for an adult care assessment with the local authority. Information relating to carers was on display in the waiting area and leaflets were available.
• Posters informing patients about national screening programmes (breast and bowel cancer) were on display in the waiting room.
• The practice’s uptake for cervical screening (2016/17) had increased to 72% (up from 70% for 2015/16), although this was below the 80% coverage target for the national screening programme. We saw that the practice manager had altered the standard letter sent to patients to be more informative about the reason for having the test and the potential consequences of not being screened. The female GP and the practice nurse told us they carried out cervical screening tests opportunistically when patients attended the practice.
• The practice was part of a local initiative to encourage participation in the bowel screening programme. This initiative involved following up patients who failed to respond or responded inappropriately to the screening kit. The practice identified these patients on a monthly basis, contacted them and encouraged participation and ordered a new screening kit if required.
• The practice manager told us they were being supported by the breast screening team to encourage participation in national breast screening programme. The screening team were going to send letters out in different languages on behalf of the practice to patients who failed to attend their first appointment.

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 Brace Street Health Centre on 7 March 2017. Overall the practice is rated as good.

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

• There were areas where adequate arrangements to respond to medical emergencies had not been formally established to ensure timely responses to emergencies situations.

• There was a system in place for reporting and recording significant events. The practice demonstrated where they had responded and learned from safety incidents.
• The practice had clearly defined and embedded systems to minimise risks such as fire and health & safety within the premises.
• Patient Group Directions (written instructions for nurses) were not authorised for their intended use. For example, we saw that PGDs were not signed by an appropriate person.
• Data from the Quality and Outcomes Framework showed patient outcomes for some clinical areas were at or below average compared to the local and national average. The uptake of national screening programs such as breast and bowel cancer screening were below local and national averages. However, processes were in place aimed at encouraging patient uptake.
• Staff were aware of current evidence based guidance and carried out clinical audits to evaluate whether quality improvements had been achieved as a result of new ways of working. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Completed Care Quality Commission comment cards showed that patients felt they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. However, results from the national GP patient survey showed that patient’s satisfaction with some areas such as length of appointment times; appointment access and helpfulness of reception staff was below local and national averages.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. New ways of working were established in response to survey results.
• 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.

• Although the practice had an overarching governance framework, we saw areas where some systems and processes were not effectively operated. For example; systems for tracking and monitoring the use of prescription pads were not operated effectively.

• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

• In the absence of some emergency medicines used to respond to medical emergencies the practice must assess, monitor and adopt formal control measures to respond and mitigate risks.

• Implement systems to ensure Patient Group Directions are appropriately authorised to ensure medicines are administered in line with legislation.

The areas where the provider should make improvement are:

• Establish and operate effective processes to track the use of prescription stationary within the practice.

• Continue to engage with patients to ensue appropriate monitoring of medicines takes place as part of, and align with, patients care and treatment plans.

• Continue to review and monitor practice performance; implementing systems and processes to improve the quality of services in response to national and practice initiated survey results.

• Consider whether limited access to routine nursing appointments for reviews and screenings such as cervical cytology impacts on patients and continue exploring effective ways to improve the uptake of national screening programmes.

• Continue exploring and establishing effective methods to identify carers in order to provide further support where needed.

• Consider how they would support patients with hearing impairments in the absence of hearing loop.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice