This practice is rated as

Good

overall.

The previous inspection was in February 2016 and the practice was rated Good.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive at Cross Keys Practice in Princes Risborough, Buckinghamshire on 06 June 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

• 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.

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

• There was a focus on continuous learning and improvement at all levels of the organisation.

• There was a clear leadership structure and staff felt supported by management.

• The practice regularly reviewed the safety of the premises to deliver health care.

• Patients taking repeat medicines received regular review of their prescriptions.
• 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.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

Areas were providers should make improvements:

Ensure uptake of cervical screening is reviewed and actions implemented to work toward achieving the national target.

Ensure patient satisfaction is reviewed to assess the satisfaction with nursing care.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

In December 2014 we found concerns related to the recruitment of staff, identification of staff training needs and systems to monitor risk during a comprehensive inspection of Cross Keys Practice in Princes Risborough, Buckinghamshire. Following the inspection the provider sent us an action plan detailing how they would improve the areas of concern.

We carried out a follow up inspection of Cross Keys Practice on 3 February 2016 to ensure these changes had been implemented and that the service was meeting the requirements of the regulations. Our previous inspection in December 2014 had found four breaches of the regulations relating to the safe, effective and responsive delivery of services. We also found a regulation breach in services being well-led.

This follow up inspection was undertaken more than six months after the original inspection and as a result our follow up methodology would not support a re-rating. However the practice were offered the opportunity of a full comprehensive inspection which would have included a change in ratings.

The ratings for the practice have not been updated to reflect our findings however following the improvements made since our last inspection on 4 December 2014; the practice was now meeting the regulations that had previously been breached.

Specifically the practice was:

• Operating safe systems in relation to the recruitment of staff. Background, recruitment and health checks were completed for staff. This included health checks such as Hepatitis B immunity status for all clinical staff and Disclosure and Baring Service (DBS) checks for all clinical staff and other staff undertaking chaperone duties.

• Providing staff with appropriate training to their roles and had an effective system to identify when staff when required a training update. Specifically, staff had an appropriate understanding of the Mental Capacity Act 2005 ensuring patients were able to provide consent and have their rights protected.

• Effectively monitoring the quality of service which included identification, assessment and management of potential risks to patients, staff and visitors. This included risk assessments in relation to the control of substances hazardous to health (COSHH). Each type of substance used at the practice that had a potential risk was recorded and graded as to the risk to staff and patients.

• Awaiting further adaptions to ensure the design and layout of the premises were suitable. Several steps inhibiting the access for people with mobility problems and patients with pushchairs and prams. Whilst awaiting the adaptions the step hazard has been risk assessed, a system now flags patients who require a treatment room located away from the steps and we saw the practice is ready to finalise architect adaptions and process for planning permission.

The practice had also taken full heed of our report following the December 2014 inspection with regards tackling inequity and promoting equality, for example, implementing a telephone translation service. We also saw members of the nursing team were now involved in discussions about how to run and develop the practice.

We have not changed the rating for this practice to reflect these changes, although the practice was now meeting the regulations that had previously been breached.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Cross Keys Practice is located in a converted listed building in Princes Risborough. The practice has three registered locations. This practice has approximately 14,500 patients. We carried out an announced comprehensive inspection of the practice on 4 December 2014 and we visited Cross Keys Practice, 60 High Street, Princes Risborough, HP27 0AX. This was the first inspection of the practice since registration with the CQC.

Adaptations have been made to ensure the practice is accessible. The local community has a high proportion of older patients, low deprivation and low ethnic diversity. The appointment system allows advanced appointments to be booked. Urgent appointment slots were also available. Patients told us they were able to make appointments when they needed them, although some patients told us booking an appointment could be difficult. Patients told us staff were caring, friendly and considerate. We found concerns regarding safety, particularly protecting patients from abuse.

We spoke with eight patients during the inspection. We spoke with three GPs, a trainee GP the practice manager, five members of the nursing team, receptionists and the prescribing clerk.

Cross Keys Practice was rated requires improvement overall.

Our key findings were as follows:

The practice was clean and medicines were stored safely.

Clinical care was managed effectively. Patients with health conditions were well cared for and national data placed the practice close to the national average for caring for long term conditions.

The practice did not maintain a safe environment for patients due to a lack of processes and training including chaperoning and the Mental Capacity Act 2005. There were concerns about staff recruitment.

Patient records were up to date to ensure safety in the delivery of medical care.

Patients told us the practice was caring and they felt well supported.

Physical access to the practice was poor in the older part of the building, with steps inhibiting the access for patients with buggies and prams. Level access from the car park was provided for wheelchair users and consultations were in wheelchair friendly rooms.

The leadership were not always proactive in ensuring there was a strategic plan for the practice to meet the changing needs of its patient population. The practice sought the feedback of its patients.

There were areas of improvement for the provider:

The provider must

-undertake all staff checks including DBS checks in line with DBS guidance and a risk assessment undertaken by the practice (this must include staff performing chaperoning) and health checks such as Hepatitis B immunity status.

-identify and monitor the training needs of staff to ensure they have an appropriate awareness in key areas of health provision including; the Mental Capacity Act 2005, information governance, equality and diversity and safeguarding vulnerable adults and children.

-effectively monitor the quality of the service and identify, assess and manage risks to patients and others including; the appointment system, control of substances hazardous to health assessments, information security, staff training and consistently identify, record and investigate incidents and disseminate learning from significant events to staff.

Additionally the provider should:

-consider all patients needs and respond appropriately to ensure they can access the practice safely and where possible independently, including phone translation services and supporting reception staff to identify patients who require additional support

-Involve nurses in clinical governance including audits and meetings

-improve its strategic and clinical leadership to ensure that the statement of purpose is reflected in practice. Potential changes to demands, staffing and other contingencies should be planned for and managed.

We have issued compliance actions for Safety and Suitability of Premises, Monitoring and Assessing the Quality of the Service, Requirements Related to Workers and Supporting Workers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice