This practice is rated as Inadequate overall. At the previous inspection in August 2018 the

practice was rated as requires improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Christmas Maltings, Clements & Keddington Surgery on 24 January 2019 as part of our inspection of Suffolk GP Federation.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We concluded that:

• Improvements had been made from our previous inspection in August 2018. However, we found a number of new concerns during this inspection.
• Patients were not always able to access care and treatment in a timely way and feedback from patients in relation to accessing the practice was poor. The practice had implemented changes to improve access and were planning to evaluate the impact of these changes.
• Quality Outcomes Framework data was significantly lower than local and national averages for some indicators.
• Patients we spoke with on the day of the inspection and feedback from patient comment cards received demonstrated that patients were positive about the caring nature of staff.
• We found complaints were handled appropriately and within a timely manner.
• Systems and processes did not ensure people were always adequately protected from avoidable harm.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

We rated the practice as requires improvement for providing safe services because:

• We found out of date medicines in the dispensary refrigerator.
• The practice could not evidence up-to-date and accurate children and adult safeguarding registers.
• The practice did not always have oversight of equipment calibration.

We rated the practice as inadequate for providing effective services because:

• The practice did not have an effective system in place to conduct medicine reviews.
• The practice’s 2017/2018 QOF achievement for all long-term conditions was significantly lower than the CCG and England averages. We reviewed unverified data from 2018/2019 and found minimal improvements had been made.
• The practice could not provide evidence to show they were assured of the competence of clinical staff employed in advanced practice. When we reviewed the consultations of clinicians, we found these were not always documented in line with national guidelines.
• We found a number of computer system coding issues which meant we were not assured that patients were always receiving the correct care, treatment and monitoring for their conditions.

We rated the practice as good for providing caring services.

We rated the practice as requires improvement for providing responsive services because:

• Patient satisfaction in relation to accessing the practice was low; results from the GP National Patient Survey was significantly below the CCG and England averages. The practice’s complaints records also supported this. The practice had implemented changes to improve access and were planning to evaluate the impact of these changes. However, it was noted 98% of patients stated that at their last general practice appointment, their needs were met.

We rated the practice as inadequate for providing well led services because:

• Despite Suffolk GP Federation C.I.C having systems and processes in place to try and ensure leadership and governance at the practice, this was not effective as there was a lack of clinical oversight at the practice level.
• The practice could not evidence that risks, issues and performance were managed and could not demonstrate actions taken in response to poor performance such as outcomes for patients with long-term conditions.
• Despite a comprehensive audit programme undertaken by the provider, Suffolk GP Federation C.I.C, the quality improvement methods in place did not ensure risks and performance was effectively managed at the practice.
• The practice could not provide evidence they were assured of the competence of clinical staff employed in advanced practice.

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:

• Establish effective systems to record all dispensing errors and near misses to ensure trends can be analysed and action taken to prevent reoccurrence.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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.

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

This is the first inspection of Clements & Kedington Surgery practice under the provider of The Suffolk Federation. We had inspected the practice under the previous provider in December 2014 and the practice was rated as good. The Suffolk Federation took over the practice in July 2017.

The practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Clements and Kedington Surgery on 9 August 2018 as part of our inspection programme.

At this inspection we found:

• The practice had been taken over by the Suffolk Federation which was a not for profit health organisation.
• The practice had seen a significant number of clinical and non-clinical staff leave the practice and experienced difficulties in recruiting GPs. However, they reviewed the skill mix required and had been successful in recruiting other staff.
• The practice used a wide range of comprehensive risk assessments to ensure issues were identified, mitigated, improvements made and monitored effectively. These were translated into detailed action plans which were monitored regularly by the practice management but also by the Federation board. For example, a backlog of medicines reviews had been identified and clinical resources were allocated to address the issue.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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.
• Due to staff shortages the practice recognised that the Quality and Outcome framework performance for 2017/2018 had reduced in some indicators and their performance was lower than the 2016/2017 data that relates to the previous provider. We saw that an action plan was in place along with additional clinics as they aimed to improve patient outcomes.
• The practice had implemented a new telephone and appointment system in May 2018. Patients we spoke with told us they found the appointment system easy to use and reported that they could access care when they needed it.
• The practice had experienced poor patient satisfaction but changes they had made had resulted in lower complaints and more positive comments and improved staff morale however the new systems had only been place since May 2018 and the management team had not had the opportunity to fully evaluate them to ensure they could be sustained and were effective to improve patient satisfaction.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to review and monitor the actions plans in place relating to security, medicine reviews, and staff immunisations to mitigate identified risks, sustain and make further improvements.
• Monitor and improve the practice performance and practice improvement plan in relation to the quality and outcome framework and ensure that all patients receive their annual reviews in a timely manner in particular to those relating to long term conditions including those affecting older people.
• Monitor the National Patient Survey data and continue to make changes and monitor the impact of those changes to improve the experience of patients in relation to access to the practice and monitor the impact of those.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.