Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 10 February 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 the legal requirements in relation to the breach of Regulation 12, 16 and 17.

The purpose of this comprehensive inspection was to ensure that sufficient improvement had been made following the practice being given an overall rating of Requires Improvement as a result of the findings at our inspection on 10 February 2015. We also checked that they had followed their action plan from the last inspection and to confirm they now met their legal requirements.

Following this most recent inspection on 2 March 2017 we found improvements had been made which has resulted in the practice being given an overall rating of Good.

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

• We found that the system in place for significant events had been reviewed. The policy had been updated. Investigations were detailed and actions were identified and implemented and meetings minutes represented the discussion that took place.

• Overall risks to patients were assessed and well managed.

• The practice had reviewed and updated its disaster handling and business continuity plan.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However we found that this guidance was not discussed at meetings held within the practice.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Monitoring of staff training now took place but further work was required to ensure that all staff completed mandatory training.
• CQC comments cards were reviewed told us that patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns and lessons were shared with staff.
• The practice had open surgery each weekday morning and patients could choose which GP they saw.
• 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.
• Regular governance meetings were now held and minuted.
• Policies and procedures had been reviewed and updated where appropriate.
• The provider was aware of and complied with the requirements of the duty of candour.

The provider should:

• Ensure the newly introduced processes for assessing the suitability of tablets and capsules for inclusion in weekly blister packs, and for accuracy checking the preparation of the packs are established and monitored.

• Implement and monitor the revised procedure for handling patient safety alerts to ensure that they are received and acted on

• Continue to monitor and further embed the current systems in place for safeguarding, high risk medicines and staff training.

• Ensure water temperature monitoring for legionella takes place on a monthly basis.

• Ensure all staff files have the appropriate recruitment documents as per the practice policy.

• Consider discussion of national guidance and guidelines at practice meetings to ensure all clinicians are kept up to date.

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 Thorpe, Burgess, Jones and Stone at Moulton Medical Centre on 10 February 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. It also required improvement for providing services for the all the population groups. It was good for providing effective, caring and responsive service.

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

• There was not a clear system for reporting incidents, near misses or concerns, therefore evidence of learning and communication to staff was limited. However, staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Complaints had been investigated fully. However learning from complaints was not consistent in the evidence we looked at. Information about how to complain was readily available.
• Risks to patients were assessed and managed, with the exception of those relating to control of substances hazardous to health.
• Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, but some were overdue for review.
• The practice did not hold governance meetings. Issues were discussed at ad hoc meetings with the GP partners.

The areas where the provider must make improvements are:

• The practice must have a robust disaster handling and business continuity plan .

• Embed a system to manage and learn from significant events.

• Embed a system to manage and learn from concerns and complaints.

• Ensure that the COSHH risk assessment and data sheets are updated on a regular basis.

In addition the provider should:

• The practice should have practice meetings which are regular, structured and relevant to give all staff the opportunity to take part, where information is shared and lessons learnt.

• Policies and procedures should be reviewed and updated on a regular basis

• Ensure that prevalence, for example, patients with depression, are coded correctly on the electronic patient record system.

• Undertake further work to ensure the practice capture patients with undiagnosed dementia.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice