Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at Burnham Surgery on 30 August 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 31 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our inspection on 31 January 2017, we looked at whether the improvements at both inspections had been made. This inspection was a follow up to our previous comprehensive inspection at the practice in March 2016 where breaches of regulation had been identified and the practice had been placed in special measures.

At the inspection in January 2017 and we found that the practice had improved. The practice was rated as requires improvement for providing safe services, and good for effective, caring, responsive and well-led services.

The full comprehensive reports on the March 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Burnham Surgery on our website at www.cqc.org.uk.

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

• The practice had a written fire risk assessment that was completed in June 2017. The practice had undertaken actions from this and other work was underway.

• Systems were in place to monitor performance and quality ensuring tasks such as changes to prescriptions and coding of records was carried out safely. The practice had a consistent process to ensure that all changes to prescriptions were authorised by a clinician.

• A qualified dispenser who worked to an agreed protocol reviewed the medicines of patients discharged from hospital. This included referral to a GP where required. The practice had plans to commence regular monthly audits of 25 patient records to ensure that errors did not occur. However, on the day of our inspection this had not commenced.

• The practice had a contract with the pharmacy and the dispensary were looking to sign up to the Dispensary Services Quality Scheme (DSQS). The dispensary completed audits to monitor its effectiveness.
• The practice were continuing to demonstrate GP leadership to ensure improvements were implemented, embedded and sustainable to continue to improve patient care.
• The practice had a system in place to evidence and document that the learning from significant events and relevant information had been cascaded to all members of staff. However not all significant events had been documented on the incident reporting forms, despite them been discussed in clinical meetings.
• Practice policies and procedures were fully documented and the most up to date versions were easily accessible to all practice staff.

• The process for acting on patient safety and medicine alerts had been reviewed so that all relevant clinicians were able to action the alerts when received.

• The management had oversight to ensure that all practice staff had received all the training appropriate to their role and in the appropriate time frame.

Actions the practice SHOULD take to improve:

• Commence regular monthly audits that were planned to assure the practice the medicines of patients discharged from hospital were appropriately actioned in line with the protocol.

• Review the process for recording significant events to ensure the incidents are recorded in line with practice policy.

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 Burnham Surgery on 31 January 2017. This inspection was a follow up to our previous comprehensive inspection at the practice in March 2016 where breaches of regulation had been identified. The overall rating of the practice following the March 2016 inspection was inadequate and the practice was placed in special measures for a period of six months.

We also carried out an unannounced focused inspection in May 2016 where we saw some improvements had been made but these were insufficient. We issued a warning notice where improvements were required in relation to good governance and requirement notices in relation to Person-centred care, Need for consent and safe care and treatment.

At our inspection on 31 January 2017, we looked at whether the improvements at both inspections had been made and we found that the practice had improved. The practice is now rated as good overall with requires improvement for providing safe services.

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

• There had been recent changes in the GP partnership and locum GPs supported the two GP partners. There was evidence that the leadership and management structure of the practice had improved significantly since our last inspection.

• We found that all of the issues from the previous two inspections had been actioned but there were some areas where further improvement was required. Governance systems had improved but the practice needed additional time to embed their new processes to ensure that the improvements could be sustained over time. Practice staff told us that they felt supported by and found the new management members and structure beneficial. Practice staff reported that positive changes had been made and felt engaged in the improvements that were being implemented.

• The GP partners with the support of the nurse manager were supporting nurses and a pharmacist to gain their prescribing qualifications.

• We saw that practice protocols and policies were now in place but some of these needed to be reviewed to bring them up to date and to be made more readily available for staff.

• There was a system for recording significant events and complaints; these had been completed in a timely manner. These were discussed at management level meetings and actions taken. Learning had been shared with the staff but this was not always recorded. The practice showed us their development plan to ensure that meetings with practice staff were regularly held and minutes taken that included the sharing of learning.

• A system for acknowledging and sharing patient safety and medicine alerts and new clinical guidance had been implemented. Records showed that safety alerts were being actioned appropriately and shared with clinical staff, although a minor improvement was required in relation to accessing the alert by additional staff when it was received by the practice.

• There was inconsistency in the processes used to ensure that all changes to prescriptions were authorised by a clinician with reference to the patient records.

• There was a new system in place for tracking the use of prescription stationery throughout the practice.

• The practice had received support from the CCG and the practice had made the improvements required to their infection control systems and processes. Relevant staff had received training.
• Since our last inspection, the practice had engaged the services of health and safety specialists. A comprehensive health and safety risk assessment had been undertaken in November 2016, but there were outstanding actions from this assessment that still required action at the time of the inspection. In relation to fire safety, the practice had some safety procedures in place but did not have a complete written fire risk assessment.
• There was a system in place to ensure patients receiving high-risk medicines had received appropriate monitoring prior to receiving repeat prescriptions.
• Staff undertaking chaperone roles had all received training and had received disclosure and barring service checks.

• The practice had a contract to dispense medicines to some of their patients and had an arrangement with the pharmacy, which was located in the same building. On the day of the inspection, the contract between the practice and the pharmacy owner had not been agreed. This posed a risk to patients as without a contract, effective monitoring of the system could not take place.

• The practice had completed clinical audits to improve patient outcomes, changes had been made and improvements seen. The practice had not monitored the performance and quality of tasks, such as coding of medical records and changes to prescriptions which non-clinical staff were responsible for to ensure safety.
• Practice staff had received training appropriate to their roles but the management oversight needed to be improved to ensure that updates would be undertaken at the appropriate time.

• The areas where the provider must make improvements are:

• Ensure a written fire risk assessment is undertaken and actions taken to keep patients and staff safe from harm. Ensure that the practice mitigates the risks to the health and safety of patients and staff as identified in the specialists risk assessment of the practice.

• Ensure systems are in place to monitor performance and quality in relation to prescriptions and the coding of records.
• Ensure that work is continued with the community pharmacy to secure the dispensing service and monitor its effectiveness.

In addition the provider should:

• Continue to demonstrate effective GP leadership to ensure improvements are implemented, embedded and sustainable to continue to improve patient care.

• Implement a system to evidence and document that the learning from significant events and relevant information has been cascaded to all members of staff.

• Review the process and implement any changes so that there is a consistent approach to ensure all changes to prescriptions are authorised by a clinician with reference to the patient records.

• Implement a system to ensure that the practice policies and procedures are fully documented and that the most up to date versions are easily accessible to all practice staff.

• Review the process for acting on patient safety and medicine alerts so that all relevant clinicians care able to action the alerts when received.

• Improvement the management oversight to ensure that all practice staff have received all the training appropriate to their role and in the appropriate time frame.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an unannounced focused inspection at Burnham Surgery on 11 May 2016. This inspection was carried out in response to risks identified at a previous comprehensive inspection on 31 March 2016.

Following our initial inspection, the practice was rated as inadequate overall, inadequate for providing safe, effective and well-led services and as requires improvement for providing caring and responsive services. In response to these concerns we requested an action plan from the provider detailing how and when these risks would be reduced.

The unannounced inspection was carried out to ensure these specific risks were being addressed and to monitor the progress being made by the provider.

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

• Practice policies and procedure were being reviewed and updated as required.
• A system for recording significant events had been implemented, although these were not always completed in a timely manner and learning outcomes were not shared with all staff.
• A system for acknowledging and sharing safety alerts and new clinical guidance had been implemented.
• Non-clinical chaperones were not being used until Disclosure and Barring Service (DBS) checks had been completed. Clinical staff had now received these checks.
• Staff training had been undertaken to ensure all staff had appropriate safeguarding training, awareness regarding the Quality and Outcomes Framework as well as additional computer skills training.
• A risk assessment regarding infection control had been carried out to address our immediate concerns but was incomplete to ensure all risks were addressed.
• Since our last inspection advice and quotations had been sought to address the concerns regarding legionella and other risk assessments including health and safety had been carried out but were incomplete.
• Consent was no longer being sought by non-clinical staff. Most clinical staff sought and recorded consent appropriately although there was some evidence of consent not being recorded.
• Patient referrals were often incomplete and lacked details of an examination or patient history.
• There was no robust system in place to ensure patients receving high risk medicines had the appropriate blood tests prior to receiving repeat prescriptions.
• There was no programme of clinical audits to drive improvement in patient outcomes.
• There was no multi-disciplinary care taking place, although staff were attempting to arrange meetings to discuss this.
• We were made aware of two GP partners tendering their resignation. There was a lack of leadership from a partnership level, although other staff were working towards addressing our concerns and to drive improvement.

The areas where the provider must make improvements are:

• Record and respond to significant events in a timely way and share learning outcomes.

• Implement a system of multidisciplinary care.

• Complete risk assessments for infection control and health and safety and address concerns raised and continue to address the risk of legionella.

• Carry out clinical audits and re-audits to improve patient outcomes.
• Implement a robust system for the repeat prescribing of high risk medicines.
• Demonstrate effective leadership to ensure patient care continues during a period of transition and a change of partners.

In addition the provider should:

• Ensure consent is sought and recorded in line with practice policies.

• Continue to review and update procedures and guidance.

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 Burnham Surgery on 31 March 2016. Overall the practice is rated as inadequate.

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 staff acting as chaperones had not received a Disclosure and Barring Service checks and no formal risk assessment had been completed. Risks in relation to health and safety, fire, legionella and infection control had either not been undertaken or managed effectively.

• The practice had a number of policies and procedures to govern activity, but some were outdated and no longer reflected current procedures.
• There was no system in place to ensure staff received, understood and implemented national guidance and guidelines.
• Patients in need of palliative care, at risk of deterioration or developing a long term condition were not being pro-actively identified and those that had been were not receiving effective care and support.

• Staff were not all clear about reporting incidents, near misses and concerns. Those reported were not all recorded in sufficient detail and there was a lack of evidence to reflect that learning had been shared with staff.

• The system in place to manage safeguarding concerns for children and vulnerable was not robust. Some staff had not received training and GPs were unaware how to identify these patients on the computer system.

• There was no robust system in place to ensure staff had completed training appropriate to their role.

• The practice operated a dispensing service out of the community pharmacy on site. Although dispensing practice was in line with legislation, there was little governance in place to agree procedures and protocols between the practice and the pharmacy and we were not provided with evidence of any medicines audits taking place.

• Prescription use was not being monitored and prescriptions were left in unlocked rooms.

• Data showed patient outcomes were low compared to the locality and nationally and there was no evidence of the practice addressing these areas of poor performance. Although some audits had been carried out, these were incomplete and we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Although staff told us multi-disciplinary meetings took place, we were not provided of sufficient evidence of this. There was a lack of understanding of the importance of patient registers, patients were not being appropriately coded to ensure reviews and referrals could take place.
• Consent was not being sought appropriately; non-clinical staff were gaining consent from patients without providing sufficient information.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity. Confidentiality in the reception area could not be ensured, conversations could be overheard and there were no measures in place to minimise this risk.

• Complaints were dealt with in line with legislation, recorded appropriately and reviewed annually.

• There was no robust system in place to ensure deceased patients did not receive inappropriate communication from the practice.

• Information about services and how to complain was available and easy to understand.

• Appointments were available; however we were told by patients we spoke with of difficulties in getting an appointment with a named GP and data showed patients regularly waited more than 15 minutes after their appointment time.

• The practice had sought feedback from patients and had an active patient participation group; however the practice had not conducted a patient survey since 2014.
• There was no system in place to ensure the practice reviewed the needs of the local population by engaging with the CCG and other organisations.
• Staff received annual appraisals. Not all staff were aware of roles and responsibilities within the practice.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements. There were no plans in place to formalise the practice vision, values or strategy.

The areas where the provider must make improvements are:

• Ensure there is a system in place to enable staff to consistently identify and record significant events, incidents and near misses. Implement a system to ensure this information is shared and that learning is cascaded to relevant staff.

• Take action to identify and address risk at the practice. This includes risks regarding infection prevention and control, fire, health and safety and legionella.

• Ensure that the lead for infection control is appropriately trained.

• Ensure there is a system in place to ensure staff receive training appropriate to their role including safeguarding training, basic life support and infection control.

• Ensure systems are in place to robustly monitor children and vulnerable adults.

• Ensure chaperones are appropriately checked through the Disclosure and Barring Service or a formal risk assessment takes place regarding this issue.

• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

• Ensure the health conditions of patients are identified and coded appropriately, including palliative care patients, to enable reviews to be effectively carried out, thereby improving QOF performance and to ensure that the sharing of information with external organisations such as out of hour’s providers is effective.

• Ensure consent is gained appropriately and that all clinical staff know how to record this.

• Carry out clinical audits including re-audits to ensure improvements have been achieved.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• 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.

• Staff should have an adequate understanding of the computer system to enable them to recognise coded patients such as patients at risk.
• Improve the governance arrangements at the practice to ensure there is effective oversight of all issues and that the services provided are regularly assessed and monitored. Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
• Ensure there are regular multidisciplinary meetings held and documented and that patient records are updated appropriately.

The areas where the provider should make improvement are:

• Improve processes for making appointments with a preferred GP.
• Review the needs of the patient population.
• Ensure patients records are appropriately updated so that staff are aware when a patients is deceased to prevent inappropriate communication with a relative.
• Improve the recall system for checking cervical screening test results and the recall system for patients who have not attended screening appointments.
• Implement suitable agreements between the pharmacy and the practice dispensary service to govern activity.
• Put appropriate measures in place to protect patient confidentiality in the reception area.
• Have a practice vision, values and strategy in place that is shared with staff and ensure that staff are aware of their own and other’s roles and responsibilities and how they impact on the performance of the practice.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains 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 practice 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.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We inspected Burnham Surgery on 21 January 2014.

We saw there were notices in the waiting room to provide people with information such as health promotion, safeguarding and other support services.

People told us they experienced treatment and care that met their needs. We received positive comments from nine people about the care provided by the surgery. For example one person told us: “The care is excellent, I receive regular monitoring for my condition and advice.” and another person told us: “The reception staff are very polite and tolerant, I can’t praise them enough.”

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms.

We saw the surgery had appropriate medicines management arrangements in place.

Staff told us they were supported well and received annual appraisals as well as appropriate training and development for their roles.

We saw that both paper and electronic records held at the surgery were accurate, appropriately maintained and kept securely.