This practice is rated as requires improvement overall. (Previous inspection report published 17 September 2015 - Good)

The key questions are rated as:

Are services safe? - Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

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 – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

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

We carried out an announced comprehensive inspection at Cutlers Hill Surgery on 12 March 2018 as part of our regulatory functions.

At this inspection we found:

• There was an effective system for recording, reporting, investigating and learning from significant events. However, the monitoring of identified learning to completion, was not always documented.
• The practice had good systems for monitoring patients on high risk medicines; medicines which require additional monitoring.
• The system in place for checking emergency medicines and equipment was not effective. Checks had not been documented since December 2017. We found three medicines, and equipment which was out of date. A GP partner confirmed during the inspection that these medicines and equipment had now been disposed of.
• The practice had some systems to manage risk so that safety incidents were less likely to happen. However, risk assessments were not all up to date and identified actions were not all documented, reviewed and monitored to completion.
• The practice provided a minor injury service for registered, non-registered patients and temporary residents.
• 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. Weekly, monthly and informal meetings were held where patients were reviewed with a range of other clinicians.
• Staff were encouraged and given opportunities to develop and provided protected time and training to meet their needs and the needs of the service. The practice had a spreadsheet of staff training; however this was not up to date and made it difficult to have oversight and assurance that staff received all training appropriate to their roles.
• Support and monitoring was in place for the nursing staff which included those with advanced roles. Three dispensary and six non-clinical staff had not received an annual appraisal in the previous year, although these had been re-booked for seven of the staff.
• Results from the July 2017 national GP patient survey were in line with and above the Clinical Commissioning Group (CCG) and national averages for patients being treated with compassion, dignity and respect, being involved in decisions about their care and treatment and satisfaction with how they could access care and treatment. Feedback from care home representatives, and patients we spoke with and received comments from supported these findings.
• Information on the complaints process was available for patients at the practice and on the practice’s website. There was an effective process for responding to, investigating and learning from complaints. However, the monitoring of identified learning to completion, was not always documented. Responses to patients were timely; however they did not detail information about escalating complaints to the Parliamentary and Health Service Ombudsman.
• Leaders had the capacity and skills to deliver high-quality, sustainable care. They were knowledgeable about issues and priorities relating to the quality and future of services. However, the practice did not have a documented vision, set of values or strategy.
• Staff told us they were happy to work at the practice, received training for their role and were encouraged to raise concerns and share their views.
• There was a focus on learning and improvement within the practice. The practice was a training practice for GP trainees. (A GP trainee is a qualified doctor who is training to become a GP). It was also a teaching practice for medical and nursing students.
• One of the GP partners had developed a computerised system to ensure that blood tests were requested appropriately according to clinical need and not repeated unnecessarily. This work had been shared with the Clinical Commissioning Group (CCG) with a view to sharing it more widely.

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:

• Develop an effective system to give oversight and assurance that staff receive all training appropriate to their roles and receive an annual appraisal.
• Continue with plans encourage uptake of annual health checks for people with a learning disability.
• Information about the Parliamentary and Health Service Ombudsman should be included in all complaint response letters.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Cutlers Hill Surgery has a practice population of approximately 10300 patients. The surgery offers a medicine dispensing service for patients who lived in excess of one mile of a pharmacy.

We carried out a comprehensive inspection at Cutlers Hill Surgery on 9 October 2014 to explore the standards of care and treatments that patients received.

We have rated each section of our findings for each key area. The overall rating was requires improvement. This was because some improvements were needed for safety and well led in respect of management of and dispensing medicines to patients. Other aspects of the service were rated as good for effective, caring and responsive for the population it served.

Our key findings were as follows:

• We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the care they received. The patients we spoke with told us they were able to make informed decisions about their care and that they felt in control.

• We found that the practice was clean. Patients we spoke with were always satisfied with the standards of hygiene at the practice.   

• There was a higher than average older population of 3257 patients. Of those 172 were housebound or lived in a care home. This resulted in a high number of regular home visits needed by GPs and practice nurses to cope with patient’s needs.

• To cope with higher demands for appointments on Mondays and following bank holidays two GPs were on call to assist with patients in receiving same day appointments. Patients told us they could see a doctor when they needed to.

• Systems were in place for identifying patients who were at risk and those who had complex needs. Care was provided using a multidisciplinary approach. 

However, there were also areas of practice where the provider needs to make improvements. 

In addition the provider should:

• Serious dispensing errors should be reported to the practice manager and lead GP and treated as significant events.

• Risk assessments should be carried out for the remote collection point for dispensed medicines to ensure a safe system was in place.

• The practice manager assured us they would make improvements to ensure safe storage of medicines and checks of controlled drugs carried out more regularly.

• There was scope to improve the governance of dispensary staff by introducing additional accountability from the management team and to improve channels of communication and review of staffing levels.
• Patients should be informed of who their named GP is.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cutlers Hill Surgery on 18 February 2019 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor and a member of the medicines team.

We previously inspected the practice in January 2015 we rated the practice as requires improvement overall and requires improvement for providing safe and well led services. We inspected the practice again in July 2015 and re-rated the service as good, and good in all domains. We inspected the practice in March 2018 and rated the practice as requires improvement overall and requires improvement for providing safe and well led services. We rated the practice as requires improvement for safe because:

• The system for checking emergency medicines and equipment had not been documented since December 2017 and was not effective. We found three medicines and equipment which were out of date.
• Effective governance systems were not in place for assessing health and safety risks within the practice.

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

• The practice did not have a documented vision, set of values or strategy.
• The monitoring of identified learning to completion, was not always documented for significant events and complaints.

At this inspection, we found that the provider had addressed these areas and showed evidence of improved outcomes for patients as a result.

Our judgement of the quality of care at this service is based 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.

I have rated this practice as good overall and requires improvement for providing safe services.

This means that:

• Generally, people were protected from avoidable harm and abuse, such as with safeguarding incidents, and that legal requirements were met.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and drive care. For example, the practice regularly reviewed data from the Clinical Commissioning Group and used this to drive improvement within the practice.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met by the way in which services were organised and delivered. For example, the practice had engaged with the Social Prescribing and the local food bank charity.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• The practice encouraged continuous improvement and innovation. For example, the practice had a diverse skill mix within the practice and encouraged staff to undertake further education such as nurses undertaking prescribing courses.
• Staff reported they were happy to work in the practice and proud of the way the practice had managed with a reduced workforce.

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

• There was an ineffective system in place to manage patient safety alerts. Following our inspection, the practice took action in relation to this finding to reduce the risks to patients.
• The key to the cupboard where prescription pads were located could be accessed by all staff. Logs for prescription pads recorded the distribution of prescriptions but did not indicate those initially held by the practice.
• The practice completed regular checks of the expiry dates of medicines within the dispensary, however these were not always recorded.

We found the provider must:

• Ensure care is provided in a safe way to patients.

We found the provider should:

• Review the system for documenting the expiry dates of medicines in the dispensary.
• Embed the action plan to improve the uptake of health checks for patients with a learning disability.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice