This practice is rated as Good overall. (Previous rating July 2017 – Requires improvement overall particularly for caring and responsive.)

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 inspection at Dipple Surgery on 18 September 2018 as part of our inspection programme to follow up concerns found at the previous inspection.

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.
• 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.
• The practice had carried out a number of clinical and non-clinical audits. We found that clinical audits rarely resulted in improvements for the practice.
• The practice involved patients in regular reviews of their medicines.
• The practice had not carried out relevant reviews for patients with learning disabilities. Following the inspection, the practice had provided us with actions to improve the system to carry out these reviews.
• There was a robust system for receiving and actioning safety alerts.
• We found the practice had appropriate systems in place to monitor medicines requiring refrigeration.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Staff had received mandatory training applicable to their role and the practice provided staff with ongoing support.
• We found the practice had conducted environmental risk assessments and completed actions identified.
• The practice had identified 1.1% of its practice list as carers by highlighting them during registration and clinical consultations.
• The practice was clean and tidy and staff had reviewed infection prevention control and policies.
• Data from the national GP patient survey published in July 2018 showed patients rated the practice in line with local and national averages for all aspects of care which the practice had previously found challenging to achieve.
• We received 42 positive comment cards regarding the care and service at the practice and one mixed review.
• The practice was aware of their patient population needs and their preferences and worked to accommodate them. They had found it difficult to form a patient participation group.

The areas where the provider should make improvements are:

• Strengthen quality of clinical audits carried out.
• Improve process to carry out health checks for patients with learning difficulties.
• Continue to actively encourage patients to join the patient participation group.

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.

Letter from the Chief Inspector of General Practice

We carried out a comprehensive announced inspection on 20 January 2016. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, effective, caring and well-led services and requires improvement for providing responsive

services. As a result of the inadequate rating overall, the practice was placed into special measures for six months. Conditions were placed on the provider’s registration. These included; ensuring there was sufficient clinical staff and managerial oversight of the practice, they were not

permitted to register any new patients, they were required to submit an action plan outlining how they were to address our concerns and time scales. These were supported with monthly progress reports submitted to the commission.

On 14 September 2016, we returned to the practice and carried out a comprehensive inspection. Overall, the practice was rated as requires improvement with the safe domain being rated as inadequate. The practice remained in special measures and we issued the practice with a warning notice in relation to providing safe care and treatment at the practice.

The practice was required to be compliant with the warning notice by 20 October 2016. We conducted a focused inspection of the practice on 8 February 2017 to establish whether the requirements of the warning notice had been met. We found during this inspection that the practice had complied with the notice. However, the practice remained in special measures.

The full reports for 20 January 2016, 14 September 2016 and 08 February 2017 can be found by selecting the ‘all reports’ link for Dipple Medical Centre on our website at www.cqc.org.uk.

We then carried out an announced comprehensive follow-up inspection at Dipple Medical Centre on 06 July 2017. The practice was rated as requires improvement overall.

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

• Staff members knew how to raise concerns, and report safety incidents
• Safety information was appropriately recorded; and learning shared with all staff.
• The infection control policy met current guidance.
• Clinical audits were undertaken.
• Risks to patients and staff members had been assessed, and acted on appropriately.
• Staff members assessed and delivered patient care in line with current evidence based guidance.
• Staff showed they had the skills, knowledge, and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity, respect, and involved in their care and treatment decisions.
• Information about the practice services and how to complain was available and easy to access.
• The practice complied with the requirements of the duty of candour when dealing with complaints and significant events.
• Patient satisfaction results published in the national GP patient survey reflected that patients were not satisfied with the GPs at the practice across a number of areas measured.
• Patients said they were able to make an urgent appointment on the day.
• The practice facilities, and equipment was appropriate to treat patients and meet their needs.
• Room temperatures were recorded where medicines were stored. However, when the room temperature rose above acceptable levels we saw no measures had been taken to address this. Staff members felt supported by the GPs and practice management team.

The area where the provider must make improvement is:

• Improve patient satisfaction as identified in the national GP patient survey.

The areas where the provider should make improvements are:

• Reinforce arrangements to store medicines at the recommended room temperature, and take action when temperatures fall or rise beyond recommended levels.
• Improve the identification of carers, to allow staff to consider peoples caring responsibilities when arranging appointments or treatment.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 20 January 2016, we carried out a comprehensive announced inspection. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, effective, caring and well-led services and requires improvement for providing responsive services. As a result of the inadequate rating overall the practice was placed into special measures for six months.

On 14 September 2016 we returned to the practice and carried out a comprehensive inspection. Overall the practice was rated as requires improvement with the safe domain being rated as inadequate. The practice remained in special measures and we issued the practice with a warning notice in relation to providing safe care and treatment at the practice. The issue of concern was as follows;

• Patients remained on medicine combinations that presented a risk to their health and one medicine alert had not been actioned in a timely and appropriate manner.

The practice was required to be compliant with the warning notice by 20 October 2016. We conducted a focused inspection of the practice on 8 February 2017 to establish whether the requirements of the warning notice had been met. We found;

• The practice had a safe and effective system in place to ensure the timely actioning of patient safety and medicine alerts. We checked patient records and found that patients were being reviewed in accordance with guidance.

The practice had complied with the notice. However, the practice will remain in special measures until their inspection in 2017. 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.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 20 January 2016, we carried out a comprehensive announced inspection. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, effective, caring and well-led services and requires improvement for providing responsive services. As a result of the inadequate rating overall the practice was placed into special measures for six months. Conditions were placed on the provider’s registration. These included; ensuring there was sufficient clinical staff and managerial oversight of the practice, they were not permitted to register any new patients, they were required to submit an action plan outlining how they were to address our concerns and time scales. These were supported with monthly progress reports submitted to the commission.

Practices placed into special measures receive another comprehensive inspection within six months of the publication of the report, so we carried out an announced comprehensive inspection at Dipple Surgery on 14 September 2016 to check whether sufficient improvements had been made to take the practice out of special measures.

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

• Improvements had been made in the recording and investigation of significant incidents. However, learning was not revisited to ensure changes had been embedded.
• Some improvements had been made in relation to the management of patient safety and medicines alerts. However some patients remained on medicine combinations that presented a risk to their health and one alert had not been actioned in a timely and appropriate manner.
• Staff were trained and knew who to contact in relation to safeguarding concerns.
• Improvements had been made in the management and storage of medicines. The practice had proactively addressed their prescribing practices promoting safe prescribing and regular monitoring of high risk medicines.
• Risks to patients who used services were identified and appropriate systems and processes were in place to ensure they were mitigated. Their fire risk assessment had been revised and fire safety recommendations had been actioned. However, the findings from the infection prevention control risk assessment were not being used to inform the cleaning provision.
• We found systems were now in place for the dissemination of clinical best practice.
• The practice had recognised improvements were required in the care they provided and we found that they had reduced the prevalence of exception reporting.
• Patient care was being consistently reviewed to ensure the accuracy of patient records and that appropriate reviews had been undertaken.
• Two cycle clinical audits had been conducted, their findings shared and used to inform and improve patient outcomes.
• Staff training and development needs had been addressed and they had the skills, knowledge and support to deliver effective care.
• We saw investment was being made on establishing relationships with their health and social care partners and clear notes were on patient records to communicate with out of hours provision.
• The practice had above the local and national averages for patient’s attendances at A&E. They had been audited but the results not analysed or recommendations made to identify and support patients in reducing their attendance.
• The practice had identified a low number of patients who were carers.
• Data from the National GP Patient Survey, published in July 2016 showed patients rated the practice lower than others for some aspects of care. Patients told us they had seen improvements in the care they received from staff and staff told us they felt more supported in performing their roles.
• The practice had a vision and plan as to how they intended to improve and enhance patient services to meet their evolving needs.
• Staff told us that since the January 2016 inspection they were now more involved in the way the practice was managed. They felt listened to, supported and encouraged to share their views.
• Permanent appointments had been made to the clinical team to improve continuity of patient care.
• We found the practice staff were more positive and engaging better with their patients and patient participation group representatives.
• Clinical care was no longer fragmented, clinicians had designated discussion forms and were invited to, and attended monthly clinical meetings. These were well documented and actions were recorded and followed up on to ensure their timely progression.

The areas where the provider must make improvements are:

• Ensure patient safety and medicine alerts are actioned in a timely and appropriate manner.
• Review and act on low levels of satisfaction reported by patients in the GP national patient survey.

The areas where the provider should make improvements are:

• Ensure the findings of the infection prevention control audit inform cleaning provision.
• Revisit issues previously identified in significant events, meetings and concerns to check learning has been embedded into practice.
• Act on the findings in the A&E audit to reduce the prevalence of patient attendance.
• Identify more patients who are carers and provide them with support and guidance.

This service was placed in special measures in March 2016. Insufficient improvements have been made such that there remains a rating of inadequate for providing safe services. Therefore, the service will be kept in special measures and under review. If needed this could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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 at Malling Health, Dipple Surgery, East Wing on 20 January 2016. Overall the practice is rated as inadequate.

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

• Staff understood their responsibilities to raise concerns. However, the concerns were not thoroughly investigated, significant incidents were not consistently identified, patients were not provided explanations and learning was not identified or shared to mitigate the risk of them reoccurring.
• Risks to patients were not consistently assessed and well managed. For example, there was no system for ensuring patient safety information was appropriately disseminated and action and a fire risk assessment was conducted and areas for improvement identified but not assigned to a designated member of staff for actioning or timely resolution.
• The practice was an outlier within their CCG for their prescribing behaviour, an action plan was in place but performance was not monitored and had not improved.
• National GP Patient Survey data, published in January 2016 showed patient satisfaction scores were below the local and national averages. The practice had identified priorities for actioning but had not progressed the tasks.
• Medicines were not managed safely, records showed they had exceeded their optimum temperatures and there was no evidence of actions taken by staff to ensure they were suitable for use.
• The practice had not completed any clinical audit cycles to inform and improve performance and patient outcomes.
• Staff reported working in silos, some clinical team members were not included in the dissemination of clinical guidance, unaware of clinical leads within the practice and the did not know of or attend clinical and/or practice meetings.
• Patients told us the staff were polite and treated them with compassion, dignity and respect. However, they also reported a lack of continuity in their care due to high staff turnover and poor communication between clinicians.
• Information about how to complaint was available to patients.
• Urgent appointments were usually available on the day they were requested.
• The practice had not actively sought feedback from patients and had not supported their patient participation group who reported feeling frustrated and not valued by the practice.

The areas where the provider must make improvements are:

• Ensure risks to the safety of service users are assessed, monitored, managed and mitigated. For example, ensuring risks to the safety of service users identified within the fire risk assessment are addressed.
• Ensure the proper and safe management of medicines
• Conduct thorough and transparent investigation into significant incidents and complaints and ensure that people affected receive reasonable support, an honest explanation, including actions taken and a verbal and written apology where appropriate.
• Maintain records of discussions, decisions and actions of staff in response to concerns raised.
• Assess, monitor and improve the quality and safety of services. For example, listening and responding to patient experiences and conducting clinical audits to improve practice and re-audit to improve patient outcomes.
• Assess, monitor and mitigate the risks to the health, safety and welfare of patients by disseminating patient safety information, national guidance and identifying and responding to lessons learnt from significant incidents.
• Maintain accurate patient records.
• Ensure patient safety information is actioned in a timely and appropriate manner.

In addition the provider should:

• Ensure the practice maintains cleaning records to demonstrate when, where and how rooms had last been cleaned.
• Improve engagement with patients, staff and partner health and social care services.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains 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.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice