Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Creswell and Langwith Primary Care Services on 11 May 2016. The overall rating for the practice was ‘requires improvement’ and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at Creswell and Langwith Primary Care Services on 15 February 2017 in order to assess improvements and the outcomes from their action plan. The overall rating for the practice following this inspection is good.

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

• The arrangements to keep patients safe and protected from harm had significantly improved since our previous inspection. For example, we were assured that there was an effective and timely process in place to recall patients affected by safety alerts to ensure patients were protected from potential harm. Systems to ensure the health and safety of staff, patients and visitors had been strengthened including safety testing in respect of fire and electrical safety, and the management of infection control.
• At the previous inspection the trust and practice staff highlighted to us the significant risks associated with inaccurate and incomplete patient records which they had inherited. A dedicated role had been created to summarise patients’ notes and together with a further member of staff they had undergone training in clinical coding, medical terminology and summarisation, they worked closely with clinical staff to recall patients to update treatments and review conditions where necessary.
• There is an effective system in place for reporting and recording significant events. Learning was applied from events to enhance the delivery of safe care to patients.
• New staff told us they had been supported in their induction process, at trust and practice level, and had been provided with substantial shadowing opportunities and regular clinical supervision to ensure ongoing support.
• A clinical audit programme was being used to drive improvements in clinical care and treatment.
• The trust had a clear policy and commitment to staff training. All members of the practice team had received an appraisal in the last 12 months, including the GPs, with the identification of individual training needs.
• Staff worked effectively with the wider multi-disciplinary team to plan and deliver high quality and responsive care to keep vulnerable patients safe.
• Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. National patient survey data indicated that the patients mostly rated the practice in line with others in the local area.
• The practice staff engaged with their Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. The trust had brought stability to the practice and had restructured a practice team with an effective skill mix including a pharmacist and two advanced nurse practitioners.
• Data from the national patient survey reflected that patient satisfaction with access to the service was in line with other local practices and national averages.
• Information about services and how to complain was available and easy to understand and learning from complaints was shared across the practice.
• The practice had a clear vision and the trust had invested time to engage with staff to help them develop a better understanding of what the organisation aspired to achieve and future plans for development. The practice team had subsequently developed a patient’s charter to reflect on what this meant to them.
• There was a clear understanding of the performance of the practice, which was monitored on an ongoing basis. Lead roles had been designated to staff which had resulted in a significantly greater achievement in QOF targets.
• Practice staff were clear about the leadership structure for the practice. Communication between the trust and staff working at the practice was regular and effective and staff told us they felt more involved in decisions about the practice.
• There was an active Patient Participation Group (PPG) which worked with the practice to review and improve services for patients.

However, there were some areas the trust should make improvement:

• Continue to engage with parents and carers of children to improve the immunisation uptake of five year olds.
• Continue to look at ways to increase the uptake of annual reviews of patients with a learning disability.
• Continue to consider what action needs to be taken to improve areas of lower patient satisfaction with 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 announced comprehensive inspection on 11 May 2016. Overall the practice is rated as requires improvement.

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

• The arrangements to keep patients safe and protected from harm were not always effective. For example, we were not assured that there was a robust and timely process in place to recall patients affected by safety alerts and to ensure patients were protected from potential harm.
• Some systems to ensure the health and safety of staff, patients and visitors were not robust and the trust had not followed their own policies in respect of risk assessment and safety testing in respect of fire and electrical safety.
• There was an effective system in place for reporting and recording significant events. Learning was applied from events to enhance the delivery of safe care to patients.
• Patients with long term conditions were reviewed annually. However the practice had not monitored that guidelines were followed through risk assessments, audits or random sample checks of patient records. For example patients on repeat prescriptions had not benefited from being recalled and medicines and care updated.

• The trust and practice staff highlighted to us the significant risks associated with inaccurate and incomplete patient records which they had inherited. The trust had agreed with NHS England, a process to reduce this risk by completing a review of high risk records.At the time of our inspection we were told that 50% of the patient records had been reviewed, we have since been informed that 74% of the records have been reviewed by 31 May 2016. The scale of this work was however reducing and it was not clear how this on-going risk would be managed and addressed in as timely a way as possible to protect patients from the risk of receiving inappropriate care or treatment.

• Completed clinical audits were not being used to drive improvements in clinical care and treatment.

• The trust had a clear policy and commitment to staff training, but not all staff had received training the trust deemed mandatory and staff had not received appraisals as managers were waiting for their training to deliver this.
• Staff worked effectively with the wider multi-disciplinary team to plan and deliver high quality and responsive care to keep vulnerable patients safe.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. National patient survey data indicated that the patients rated the practice slightly lower than others in the local area in a number of areas.
• The practice staff engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. The trust had brought stability to the practice and had a full clinical team in place. This was a significant achievement.

• Data from the national GP patient survey reflected that patient satisfaction with access to the service was lower than other local practices. In some cases significantly lower. These results related to a period when the trust were still recruiting, though patient comments during our inspection highlighted that waiting for appointments and continuity of care remained areas of concern. Latest data published in July 2016 showed improvement in these areas.

• Information about services and how to complain was available and easy to understand and learning from complaints was shared across the practice.

• The trust had a clear vision and had held engagement events in February and March 2015, a majority of clinical staff engaged with at the time have since left. New staff members told us they had not been sited and were not aware of the vision and strategy. There were no detailed plans to achieve the Trust vision or strategy in relation to the practice. There were no clear plans in place to effect and deliver improvements to patient care.

• There were areas where we did not find an effective and responsive framework of governance and oversight to support the delivery of high quality care. For example there was not a clear and comprehensive understanding of the performance of the practice, the staff were not clear about the leadership structure of the practice from the trust and Communication between the trust and staff working at the practice was not effective and staff told us they did not feel involved in decisions about the practice.

• There was an active Patient Participation Group (PPG) and worked with them to review and improve services for patients. They were a key reason the practice continued to operate following a difficult period and they worked closely to help improve the facilities and service patients received.

The areas where the provider must make improvement are:

Ensure patients receive safe care and treatment by ensuring all risks are assessed, monitored and mitigated in relation to the health, safety and welfare of patients, carers and staff by;

• Ensuing there is a robust and timely process in place to recall patients affected by safety alerts;
• Ensuring premises and equipment is safe for use in particular fire and electrical safety and
• Ensuring patients are protected against the risks of acquiring infections by having appropriate cleaning schedules in place for clinical equipment.
• Ensuring there is a clear plan and actions agreed to manage the risks associated with incomplete and inaccurate patient records and QOF registers in a timely way.

Ensure there are effective systems in place to enable the provider to assess and monitor the quality of care being provided and to identify, assess and mitigate risk by;

• Ensure there is appropriate leadership and oversight to ensure the support, training, supervision and appraisal of staff enabling them to carry out their role competently and effectively
• The effective use of clinical audits to enable the provider to benchmark the quality of the clinical care being provided and to drive improvements, ensuring patients are treated in line with best practice guidelines

• Ensure there is appropriate leadership and governance of the practice from the trust, reviewing and clarifying the lines of accountability and the level of autonomy between the trust and the practice.

The areas where the provider should make improvement are:

• Have guidance for the procedures following a sharps injury displayed in clinical rooms.

• Implement systems to ensure all staff receive regular appraisals and professional development as appropriate.

• Review the arrangements in place to ensure patient privacy and dignity in clinical rooms
• Consider whether a doctor’s bag with relevant emergency medicines is necessary in consultation with practice clinicians.
• Review how trust systems could be modified to ensure a greater level of responsiveness to the needs of the practice.
• Review the arrangements for ensuring better continuity of care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Creswell and Langwith Primary Care Services on 13 April 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.