We carried out an announced comprehensive inspection at Castlefields surgery on 20 March 2018. The overall rating for the practice was good with requires improvement for providing well led services. The full comprehensive report on the March 2018 inspection can be found by selecting the ‘all reports’ link for Castlefields Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 19 October 2018 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 20 March 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

• There were gaps in record keeping to support regular cleaning of the practice.
• There was no oversight of complaints or significant events, with no analysis of trends or learning taken.
• Meeting minutes lacked detail and were not a full account of what had taken place.
• There was ineffective systems to review policies and procedures.
• A legionella risk assessment had not been completed. (Legionella is a term for a bacterium which can contaminate water systems in buildings).  
• The practice was not actively encouraging patient to participate in the national cervical screening programme.
• Annual reviews for patients in vulnerable groups, such as with learning disabilities, were not competed regularly.
• An infection control audit had been carried out with ongoing actions being completed.
• Risk assessments were in place for emergency medications that were not held on site.
• There was a secure system in place for prescription safety.
• Staff in lead roles had received appropriate training.

At our previous inspection on 20 March 2018, we rated the practice as requires improvement for providing well led services due to the above governance issues. At this inspection we found that some of the concerns had been rectified however there were still some issues that had not been resolved. Consequently, the practice is still rated as requires improvement for providing well led services.

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – RI

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Castlefields Surgery on 20 March 2018. We carried out this inspection as part of our inspection programme.

At this inspection we found:

• Staff involved and treated people with compassion, kindness, dignity and respect.

• We found the documentation of some systems and processes including those identifying risk to patients required improvement.

• The practice team was small and they told us that communication was very good but it was often not documented.

• The practice had developed and embedded a clear system to ensure that meetings such as multi-disciplinary team (MDT) meetings and practice meetings were held and were inclusive of all staff however minutes of the MDT meetings we reviewed lacked detail of what was discussed, actions taken, risks mitigated and learning shared.
• There was a system for recording and acting on significant events and there were effective systems for reviewing and investigating when things went wrong. However, we found that the minutes lacked detail and staff we spoke with told us that most of the shared learning was verbal.
• The practice had systems and processes to manage and mitigate risks to patients and staff. However, during our inspection we found that risks associated with infection control had not been audited and there were no records in place to support the cleaning of the practice premises and medical equipment. Furthermore, the practice could not provide assurance that risks associated with legionella were effectively managed.
• Clinicians knew how to identify and manage patients with severe infections such as sepsis.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
• Information on the complaints process was available for patients at the practice and on the practice’s website. We found that the practice did not record all verbal complaints which posed the risk of missing themes and trends to act on for improvement. There was a process of responding to and investigating complaints but the lack of documentation did not assure us that identified learning was shared with all the staff.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Staff had the skills, knowledge and experience to carry out their roles and there was a strong focus on continuous learning and improvement at all levels of the organisation. Staff we spoke with felt supported by the practice.

• The practice had a clear process and understanding of safeguarding.

The areas where the provider MUST make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the systems to ensure patients are encouraged to attend appointments for cervical screening and patients with a learning disability are formally reviewed annually.

• Ensure that staff who undertake lead roles receive appropriate training to enable them to execute their duties properly.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice