This practice is rated as good overall (at the previous inspection undertaken in June 2015 and January 2016, the practice received a good overall rating).

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? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Dr A Palmer and J Gardner (Barlborough Medical Practice) on 21 February 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:

• There was a clear leadership structure and staff told us they felt well supported by the partners and practice manager. We observed the positive impact this had in establishing a well-integrated practice team with low staff turnover and high morale.
• GPs and practice staff worked effectively as a cohesive team and provided personalised and responsive care to their patients.
• There was an emphasis on a patient centred approach in all aspects of the practice’s work. This was underpinned by the practice’s mission statement.
• The practice directly employed a community matron and two part-time care coordinators. This impacted positively on patients from a clinical, caring and social perspective. We saw how these staff members helped to provide holistic support to patients and their families, and integrate them within the local community.
• Results from the latest national GP patient survey showed that the practice had performed either above or in line with local and national averages regarding patient experience. This was particularly evident in relation to continuity of care in being able to see a preferred clinician, and easy access in obtaining an appointment.
• The national GP survey showed that 89% of patients who responded would recommend the surgery to someone new to the area compared with the clinical commissioning group (CCG) average of 81% and the national average of 77%. This was reinforced by the Care Quality Commission (CQC) comment cards completed by patients prior to our inspection, which reflected that patients strongly valued the practice and were extremely satisfied with the care they had received.
• The practice regularly dispensed medicines to approximately 250 patients. On the day of the inspection, we found that some processes within the dispensary required strengthening to fully comply with legal requirements and recommended guidance.
• The procedure for issuing repeat prescriptions did not always comply with best practice. The number of repeat issues for patients receiving high risk medicines needed review. This was to ensure that patients were compliant with attending for regular blood checks before receiving further supplies of their medicine.
• We found that the procedure for checking medicines within the practice was not sufficiently robust and we discovered a small number of medicines and consumables that had exceeded their expiry date.
• The practice encouraged and supported staff to report incidents. We found that the procedure to apply learning from incidents was not always sufficient and required improvements to be made. The practice acknowledged this and agreed to review their process.
• The practice had a strategy and forward vision. They worked with their local CCG and practices to maximise improvements in primary care for local patients. For example, the practice were seeking a solution to NHS England’s requirementto ensure that everyone would be able to access easier and more convenient GP services, including appointments at evenings and weekends via an 8-8 service.
• We spoke with community based health, social and care home staff who overwhelmingly provided us with positive feedback about their interactions with the practice team.
• There was a focus on continuous learning and improvement at all levels of the organisation. Staff training records were mostly up to date, and regular appraisals encouraged development at all levels.
• The practice had an established quality improvement programme. This included an audit programme which demonstrated improvements in outcomes for patients.

We saw the following areas of outstanding practice:

• Weekly multi-disciplinary (Community Support Team) meetings took place which were attended by members of the practice team with community health staff, social care and voluntary sector representatives. This was supported by the analysis of current activity data, for example, from out of hours contacts and accident and emergency attendees to determine where additional support may be required for patients. The practice provided an example of a patient who was shown to be making repeated contacts with the 111 service. When this was identified, the patient was assessed and provided with a care package to suit their needs, and this resulted in a marked decrease in 111 contacts by this individual. A social care representative informed us how this helped establish appropriate care packages at the earliest opportunity to keep patients at home. This was supported by lower levels of access to acute care. The integration between practice and community teams had created an excellent understanding of respective roles and how these could work in collaboration to benefit patient care. The meetings had received recognition from the CCG as a good model for other practices to develop.
• The practice manager developed templates on the computer system to enhance accurate data collection and maximise the collation of essential patient information. These were made available to colleagues across the county to share best practice. This included a template to develop individualised care plans for patients with a long-term condition; a template to record a patient’s specific communication and access needs for sharing with other services; and a template to capture an accurate records of vaccinations and immunisations.

Importantly, the provider must make improvements to the following areas of practice:

• Ensure care and treatment is provided in a safe way to patients. For example, by reviewing procedures within the dispensary to ensure they are in line with the practice’s own standard operating procedures; establish effective internal monitoring of the expiry dates of medicines and consumables; ensuring that patients prescribed high risk medicines receive regular monitoring; and reviewing the number of issues for repeat prescriptions.

The areas where the provider should make improvements are:

• Review the procedure for incident reporting to provide improved assurance that investigations have identified the key contributory factors, and that these have been appropriately acted upon to keep patients safe.

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 of this practice on 9 June 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We did not visit the practice as part of this inspection. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr A Palmer & Dr J Gardner on our website at www.cqc.org.uk.

Our finding across the area we inspected was as follows:

• The practice had ensured that all non-clinical staff acting as chaperones had received an appropriate disclosure and barring service (DBS) check. The chaperone policy had been updated to reflect this requirement so as to protect both patients and staff.

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 Dr A Palmer & Dr J Gardner on 9 June 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing effective, caring, responsive and well-led services. It was also good for providing services for all population groups we inspected (older people, families, children and young people, people with long term conditions, working age people (including those recently retired and students, people whose circumstances make them vulnerable and people experiencing poor mental health including people with dementia). It required improvement for providing safe services.

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

• Patients overwhelmingly praised the practice staff for an excellent and person centred service.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
• Some patients commented that they found it difficult to get through to the practice by telephone in the morning; however the majority of patients said that there was good access to the practice. Urgent appointments were available the same day.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Staff had received training appropriate to their roles and further training needs had been identified and planned.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There were systems in place for recording, monitoring and reviewing information about safety and safeguarding.
• The practice took a proactive approach to working with other organisations and local practices in planning service provision for patients. This included the delivery of coordinated care in liaison with the community support team.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

• Patient feedback was overwhelmingly positive about the way staff treated people and most patients confirmed they had consistently received an excellent and caring service. This was corroborated by  positive patient survey results from different sources and external professionals we spoke with.

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

The areas where the provider must make improvements are:

• Ensure a risk assessment is in place and / or a Disclosure and Barring Service (DBS) check has been received before any member of staff can undertake chaperone duties.

In addition the provider should:

• Ensure systems in place for recording significant events and safeguarding discussions in respect of children are strengthened to give a clear and accurate picture of safety and information discussed.
• Ensure completion of e-learning by staff is actively monitored to assure the provider that staff have completed relevant training in a timely way.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A Palmer & Dr J Gardner on 21 February 2018. The overall rating for the practice was ‘Good’, however, the practice was rated ‘Requires improvement’ for providing safe services. We asked the practice to develop an action plan to address the areas of concern that were identified during our inspection.

The full comprehensive report can be found by selecting the ‘all reports’ link for Dr A Palmer & Dr J Gardner on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 October 2018 to review actions taken by the practice since our previous inspection in February 2018. This report covers our findings in relation to actions taken by the practice since our last inspection in the area of ‘Safe’.

Overall the practice remains rated as ‘Good’. The practice is now also rated ‘Good’ for providing safe services.

Our key findings were as follows:

• The practice had reviewed and improved their processes for repeat prescribing and the management of high risk medicines.
• The practice had reviewed and improved their processes for significant events, the Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and near misses.
• The practice had addressed previous issues identified relating to their dispensary.
• The practice had improved their systems for ensuring emergency medicines and consumables were not used past their expiry date.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice