This practice is rated as Good overall. At the previous inspection in May 2018 the practice was rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

We carried out an announced comprehensive inspection at Constable Country Medical Practice on 24 April 2019 as part of our inspection programme.

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

• Patients told us they were dissatisfied with the access arrangements for the practice, despite the changes the practice had implemented. This was supported by the GP National Patient Survey results, feedback from patients on the day of the inspection and feedback received through NHS Choices and practice complaints.
• We found the practice did not have a complete record of all patient complaints; in addition to this, the practice was unable to evidence the learning gathered from complaints and how they had made improvements to the quality of care provided.

However, we also found that:

• Since the previous inspection, the practice had appropriate arrangements in place to evidence building safety records were maintained.
• The practice had improved the coding of medical records in respect of palliative patients.
• Patients received effective care and treatment that met their needs.
• Staff told us morale was high and they felt well supported by the practice management team.

We rated the practice as good for providing safe, effective, caring and well-led services.

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:

• Monitor and improve the practice’s antibiotic prescribing rate.
• Review and improve the number of carers identified and supported by the practice.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Constable Country Medical Practice on 1 November 2015. This inspection was in follow up to our previous comprehensive inspection at the practice on 10 March 2015 where breaches of were found. The overall rating of the practice following the March 2015 inspection was inadequate and the practice was placed into special measures for a period of six months. We also issued requirement notices to the practice to inform them where improvements were needed. After the March 2015 inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to safe, effective, caring, responsive and well-led services.

At our inspection on 1 November 2015 we found that the practice had improved. The two requirement notices we issued following our previous inspection related to the safe delivery of care and good governance and both had been met. The ratings for the practice have been updated to reflect our recent findings.

The practice is rated as good overall, for providing safe, effective, caring, responsive and well led services.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said there were urgent appointments available the same day and that there was continuity of care, however we were told it was not always easy to make an appointment with the GP of their choice.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by the partners and business manager. The practice sought feedback from staff and patients, which it acted on.

There were areas of practice where the provider needs to make improvements.

Importantly the provider should;

• Improve the arrangements for the security of blank prescription forms.

I confirm that this practice has improved sufficiently to be rated Good overall. This practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our inspection on 15 May 2015, we followed up enforcement action that we had taken following our comprehensive inspection on 10 March 2015. The inspection report for the comprehensive inspection can be found on the CQC website. Following the comprehensive inspection we issued a warning notice to the practice because we felt there were immediate risks that required urgent attention by the practice. We returned on 15 May 2015 to ensure the practice had taken action to mitigate these risks.

Our inspection team was lead by a CQC lead inspector and a GP specialist advisor. We found the provider had made improvements in ensuring that suitable arrangements were in place to assess and monitor the quality and safety of service provision. This included the review of patients’ health conditions, risks relating to health, safety and welfare and medicines; and acting upon the recommendations from other health professionals to ensure safe care. We saw that the practice had put in place a new clinical governance structure to ensure GP oversight for all areas of the practice, ensuring that all staff were appropriately supported to deliver safe and effective care to patients. There was evidence of action taken for medicine and healthcare alerts. Patient safety alerts are issued when potentially harmful situations are identified and need to be acted on. Safety alerts were triaged by clinical members of staff and there were new systems in place for checking that these had been seen and actioned appropriately. A schedule for regular team meetings had been put in place with a GP lead in attendance for each team meeting. Systems were in place to ensure the discussion and any learning from complaints and significant events was addressed with staff at these meetings. We saw that systems had been put in place to ensure clinical meeting minutes were shared with all staff. The practice had put systems in place to ensure clinical oversight and review of all complaints and significant events. The practice had reviewed previous complaints and significant events to ensure these were in line with the practice policy and the practice could effectively assess and monitor the quality of the service provided.

We spoke with GPs, the practice manager, deputy manager, nurses and staff during our inspection. All the staff we spoke with told us that following the changes made by the practice since our previous inspection they felt better supported by the GPs and empowered to raise and address any issues. Patients we spoke with were complimentary about the improvements in the service provided.

The practice continues to operate within the special measures applied by the CQC and will continue to do so for six months. After this time, CQC will revisit and re-inspect Constable Country Rural Medical Practice and will amend our judgments and ratings.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Constable Country Medical Practice on 10 March 2015. Overall the practice is rated as inadequate.

Specifically we found the practice was inadequate for providing a safe, effective and well led service. We found the practice requires improvement for providing caring and responsive services. We examined patient care across the following population groups: older people; those with long term medical conditions; mothers, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health. We found the provider was rated as required improvement for caring and responsive for each of these population groups. They were rated as inadequate for safe, effective and well led. All of the population groups are also rated as inadequate as the concerns which led to our ratings across each of the domains also apply to each of the population groups.

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

• Some patients were satisfied with the appointment system. Some patients reported that it was difficult to get through on the telephone and some patients were dissatisfied with the length of time they waited after arriving for their appointment.
• Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw no evidence that audits were consistently driving improvement in performance to improve patient outcomes.
• Non clinical staff were responsible for assessing risks to patient safety with no clinical oversight or accountability to ensure appropriate actions had be taken to safeguarding patient safety.
• Not all practice staff were aware of how to report safety incidents and near misses that occurred.
• Records were not accurately maintained to reflect significant incidents and there were not effective systems in place to ensure learning was shared to mitigate the risk of reoccurrences.
• Patients did not have their clinical care reviewed in accordance with the practice policy.
• The practice failed to promote an open and transparent culture for staff to report concerns and there was limited evidence of the practice learning from complaints.
• Patients said they were treated with compassion, dignity and respect.
• Information about services and how to complain was available.
• Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait two weeks for non-urgent appointments.
• The practice had not proactively sought feedback from staff or patients.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Implement effective systems for the management of risks to patients and others against inappropriate or unsafe care. This should include arrangements for managing significant events, safety alerts and audits etc. Complete clinical audits to identify that care is being provided in line with standards.

• Ensure that there are documented checks of the cleaning that is undertaken. Infection control audits need to be undertaken, with actions identified and completed.
• Ensure that processes are in place for sharing the learning from significant events and complaints with all staff.
• Ensure there are adequate systems in place for the disposal of patient prescribed medicines.
• Ensure that safe and clinically supervised systems are in place for reviewing of all patient correspondence and actioned in a timely way and that clinical coding of patient data is accurate.

In addition the provider should:

• Conduct risk assessments for staff undertaking chaperone duties.
• Complete clinical audits to identify that care is being provided in line with standards.
• Ensure clinical staff have a clear understanding of how to ascertain parental responsibility and understand what is required for a child to be considered to be Gillick competent.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We conducted this inspection to follow up on the compliance action made at our last inspection on 02 July 2014, when we found that seven staff had not received an appraisal and the training deemed mandatory by the practice, had not been completed by approximately one third of staff. This training included health and safety, fire safety, infection control, equality and diversity, manual handling, safeguarding adults and children and information governance.

During our inspection on 03 December 2014 we found that improvements had been made.

We looked at the records of appraisals and mandatory training and found the majority of staff had received an appraisal and had completed training deemed mandatory by the practice.

We were told by the practice manager that the majority of staff had received an appraisal and completed mandatory training. We spoke with three members of staff who confirmed this. One member of staff told us, “I attended a study day last week which was agreed at my appraisal.”

We were assured by the provider that mandatory training for four staff and the appraisal for one member of staff which remained outstanding, would be completed within two weeks of the date of this inspection. On 15 December 2014, we received evidence from the provider to confirm that these had been completed.

We conducted this inspection to follow up on the compliance action made at our last inspection on 26 February 2014, when we found that training deemed mandatory by the provider had not been completed by approximately two thirds of staff. This included training in health and safety, fire safety, infection control, equality and diversity, manual handling, safeguarding adults and children and information governance. In addition, there was no evidence of documentation of induction for new staff or that the provider had an effective staff appraisal process in place.

During our inspection on 02 July 2014 we found that some improvements had been made. We looked at the records of the two newest members of staff and saw that an induction checklist had been completed. We noted that that a ‘Medical student and locum information pack’ had been given to the locum who was working at the surgery on the day of our inspection.

However, approximately one third of staff had not completed the training deemed mandatory by the provider and seven staff had not received an appraisal. This meant that not all staff had received training and support relevant to their role so that people received safe care and treatment and to an appropriate standard.

We spoke with five people who used the surgery all of whom confirmed that their privacy and dignity was maintained by the staff at the surgery. People told us they were involved in decisions regarding their care and treatment but three people said this was dependent on which GP they saw.

We looked at the records of seven people and saw people’s needs were assessed and care and treatment was planned and delivered in line with their individual needs. One clinician told us, “We decide together so patients feel empowered.”

There were policies and guidelines in place for staff training, the induction of new staff and annual appraisals. We looked at four staff files and found two thirds of mandatory staff training had not been completed. In the files that we viewed, one staff member had received an appraisal in the past year and there was no documented evidence of induction.

We saw evidence that the surgery listened and responded to the views of the people who used the surgery. One person said, “It is hard to get an appointment, but more recently you can get an appointment on the day.” We were told by the practice manager that the surgery was aware telephone access was a problem and there were plans to change the telephone system so that it was more effective. We saw evidence of work towards these plans.

This practice is rated as requires improvement overall. This is the seventh inspection of Constable Country Rural Medical Practice. At our inspection dated 8 May 2015 we found the practice inadequate overall and at our last inspection 24 December 2015 the practice was rated as good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Constable Country Rural Medical Practice on 16 May 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had continued to sustain and further improve some areas which had been identified as needing improvement during our inspection in May 2015. The practice was aware of some areas which they were improving further.
• Since our previous inspection, significant changes had taken place within the staffing of the practice; three GP partners had left the practice and from January 2018 two GP partners led the practice. They had been successful in recruiting permanent staff as well as developing existing staff.
• Results of the GP patient survey July 2017 and feedback received from patients showed that patient satisfaction in some aspects of care was poor. Negative comments included those relating to GP attitude. The practice had been proactive in increasing the way they sought feedback from patients with the Patient Participation Group (PPG) and Healthwatch Suffolk who were consistently involved and had attended the practice regularly to gain direct feedback from patients using the service.
• Feedback in relation to the practice appointment system was mixed. Some patients reported they had trouble in using the appointment system and experienced delays in getting appointments. We noted that some patient feedback gathered by the PPG and Healthwatch reported that some patients had seen improvements over the recent months and liked the new triage system.
• The practice no longer dispensed medicines to patients who lived more than one mile from a pharmacy but worked with the local pharmacy which was sited at the branch site in Capel St Mary.
• Data from the quality and outcome framework (QOF) showed the practice performance as in line with or above the national and CCG averages.
• Childhood immunisations were carried out in line with the national childhood vaccination programme. The practice uptake rates for the vaccines given was positive with 100% for three of the four indicators and 95.8% for the fourth. This was above the national and CCG averages.
• There were systems to manage risk so that safety incidents were less likely to happen. When incidents happened, the practice learned from them and improved their processes but the practice did not fully evidence that learning was shared with the whole practice team.
• The practice had a system to manage complaints. We found most complaints had been managed appropriately but the practice could not demonstrate that learning was always shared with the whole practice team.
• Safety systems were comprehensive and actions were taken where necessary. Infection control audits were carried out monthly.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines.
• Clinicians had access to appropriate information to deliver safe care and treatment.
• Staff involved and treated patients with compassion, kindness, dignity, and respect.
• The practice had recently refurbished all the clinical rooms at the branch site and the refurbishment of the waiting area and reception office were due to be renovated.
• 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 monitor feedback from patients relating to the care they received and access to services to encourage improvements and monitor the impact of changes made by the practice to ensure they are effective.
• Improve the documentation to evidence that fire safety checks are conducted regularly and formally recorded.
• Improve how the practice records and shares the findings and identified learning from complaints and significant events to the whole practice team.
• Review and monitor the coding of medical records in respect of palliative care patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice.