Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bush Hill Park Trinity Surgery on 17 February 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Bush Hill Park Trinity Surgery on our website at www.cqc.org.uk.

At our previous inspection in February 2016, we rated the practice as Requires Improvement for providing safe, effective and well-led services. At this time included amongst the issues we identified, was the practice could not provide sufficient evidence that regular clinical audits were being conducted, a programme of regular in-house infection control audits had not been established and the practice did not have oxygen at its premises.

This inspection was an announced focused inspection carried out on 8 May 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 17 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe, effective and well-led services. As a result of these findings, the practice is now rated as Good for providing safe and well-led services, and requires improvement for effective.

The change in the ratings for safe and well-led, means that the practice is now rated as Good overall.

Our key findings were as follows:

• The practice had devised a written Business Continuity Plan and had reviewed and updated practice guidance and procedures within the last 12 months.
• The practice had access to oxygen, which could be used in the event of a medical emergency at the practice.
• A programme of clinical audits and re-audits had been introduced at the practice to monitor and improve patient outcomes.
• We saw evidence that on the day of inspection all but one member of staff had received a performance review in the last 12 months. Subsequent to the inspection, we received confirmation that the remaining member of staff had received an appraisal.
• The practice conducted regular fire drills. All staff members had been trained in what to do in the event of a fire.
• We saw evidence that electrical equipment at the practice had been Portable Appliance Tested (PAT) during the past 12 months.
• Staff were informed of the strategy and vision of the practice devised by the GP Partners

The areas where the practice must make improvements are:-

• Ensure that a clear record of patient health concerns, diagnosis and treatment following consultation are included on patient’s notes/treatment plan.

The areas where the practice should make improvements are:-

• Continue to review arrangements to enable patients access to a female GP

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Trinity Avenue Doctors Surgery is a small general practice (GP) service located in the London Borough of Enfield. NHS Enfield Clinical Commissioning Group (CCG) is a membership organisation of 54 local GP practices, of which Trinity Avenue is one. Enfield CCG is responsible for commissioning health services for a population of around 310,000 people in Enfield.

Trinity Avenue provides patients with a primary care service. The practice is situated in two semi-detached houses on a residential street. The practice is registered with the Care Quality Commission (CQC) as a partnership with two GPs, one of whom is the practice’s registered manager.

All the patients we spoke with were complimentary about the service they received. We received twenty three comments cards completed by patients prior to our visit. The responses demonstrated patients were consistently pleased with the service they received.

The regulated activities carried out by the practice were diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury. We found the practice provided a safe service. Mechanisms were in place to report and record safety incidents, concerns, near misses and allegations of abuse. However patients were exposed to some risk because the process for checking medication was not sufficient. We have asked the practice to take action to address this.

The service was effective at planning care and treatment and meeting patient’s needs. Patients said the practice provided a caring service. We saw good interactions between patients and staff and patient’s privacy and confidentiality were protected. Services were organised so as to meet patient’s needs.

The service was well led. There were clear lines of accountability and the leadership culture was open and supportive. Improvements could be made by practice ensuring staff were able to articulate the values and ethos of the practice. The patient participation group was highly motivated and involved however they could be used more effectively.

The service met the needs of groups such as older people, people with long term conditions, mothers, babies, children and young people, the working age populations and those recently retired. Services for those patients experiencing poor mental health could be improved. Processes were in place to ensure people with long term conditions were supported to manage their conditions and received regular health reviews. All practice staff worked together as a team to provide patients with an effective and good quality service. Patients we spoke with and comment cards we received showed patients were happy with the quality of care and treatment they had received. There was good access to appointments with patients telling us they were always able to get appointments at times that suited them.

Letter from the Chief Inspector of General Practice

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

• Although staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses, reviews and investigations were not thorough enough to learn lessons from incidents and prevent them from happening again.
• Data showed that some patient outcomes were below the local and national averages. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• The majority of patients said they were treated with compassion, dignity and respect.
• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, but some important policies were not in place. For example, there was no evidence of a Business Continutity Plan in place.
• The practice had proactively sought feedback from patients and had an active patient participation group.
• The practice had little evidence of effective processes for managing risks to patients. For example, the practice did not have oxygen on site and a risk assessment of not having oxygen had been conducted by the practice.

The areas where the provider must make improvements are:

• Put in place a Business Continuity Plan with supporting arrangements.

• Carry out regular clinical audits and re-audits to improve patient outcomes. In addition, a timetable for regular in-house infection control audits to be established
• Ensure that the practice has access to a supply of oxygen in the event of a medical emergency at the practice.
• Conduct regular fire drills and to appoint a designated lead with responsibility for fire evacuations, and that Portable Appliance Testing (PAT) of all electrical appliances used at the practice is conducted periodically.
• Ensure that all reviews undertaken are documented and that outcomes identified as a result of review are shared with all practice staff in a timely manner.
• Ensure that all staff have regular performance reviews.

In addition the provider should:

• Review arrangements to enable patient access to a female GP

• Review and update procedures and guidance in accordance with best practice and current regulation.

• Inform all staff of the vision and strategy for the practice devised by the GP partners.

•  Review practice strategy for identifying and supporting patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice