This practice is rated as Good overall. (Previous inspection December 2016 – Requires improvement)

The key questions are rated as:

Are services safe? – Good

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 – 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 – Requires improvement

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

We carried out an announced comprehensive inspection at Drs Masterton, Thomson, Bolade & Otuguor on 15 March 2018, because we had previously identified areas where the practice was failing to meet the legal requirements in delivering care.

This was the practice’s third inspection. We first inspected on 26 July 2016 when we found significant concerns relating to safe recruitment of staff, management of medicines, arrangements for emergencies, infection control, managing test results, learning from significant events, staffing levels and support for staff (including induction, training and appraisal) and overall governance, including maintenance of appropriate policies. We rated the practice as inadequate.

Before the report of the July 2016 was published, we carried out a focused inspection on 1 December 2016, because of the delay in producing a finalised report and the safety concerns identified. Despite not having had a copy of the report from the previous inspection, we found that the practice had made substantial improvements, fully addressing most concerns and with actions underway to address those that remained. There remained some issues with how medicines were managed, with infection control, training and appraisal. We therefore rated the practice as requires improvement.

More details of the findings of the previous inspections are given under the key questions, below. You can read the report from the previous inspections by selecting the ‘all reports’ link for Drs Masterton, Thomson, Bolade & Otuguor on our website at www.cqc.org.uk.

At this inspection we found:

• In general, the practice had maintained the improvements made previously. Although there were issues in some of the same areas, these were not the same as previously identified (so the issues did not reflect a failure to act by the practice).
• There were systems to assess, monitor and manage risks to patient safety, although there were aspects that needed to be strengthened, particularly related to documentation of recruitment checks.
• There was an effective system for staff training and appraisal, but the practice policy did not include all of the training recommended by national guidance.
• 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, although formal documentation sometimes followed later.
• 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.
• Measures of the effectiveness of care showed the practice was performing in line with local and national averages (although not always up to the national target). Exception rates (patients excluded from performance data) for chronic obstructive pulmonary disease were above average, but this appeared to be linked to the practice’s older population.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients told us that they found the appointment system easy to use and reported that they were usually able to access care when they needed it, although some patients reported that it could be difficult to get appointments with particular GPs and sometimes with a female GP. Patients reported that they sometimes had to wait too long after their appointment time.
• There was continuous learning and improvement at all levels of the organisation. This had after the first inspection focused on patient safety, but was extending to other aspects of the practice’s care and services.

The areas where the provider must make improvements:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please go to the requirement notice section at the end of the report for more detail.)

The areas where the provider should make improvements are:

• Review the causes of long waiting times and the below 80% cervical screening rate and consider actions.
• Consider if there are ways to improve accessibility to consulting rooms for patients with impaired mobility, and ways to support patients’ understanding, for example by using easy read materials.
• Review staff training in consent, including the mental capacity act.
• Continue to monitor high exception rates for chronic obstructive pulmonary disease to ensure exceptions remain clinically appropriate.
• Review whether there is sufficient access to female GP appointments and nurse appointments.

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 Drs Masterton, Thomson, Bolade & Otuguor on 26 July 2016. During the inspection we identified breaches of regulation 12 (Safe Care and Treatment), regulation 17 (Good governance) and regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches resulted in the practice being rated as inadequate for being safe, effective and well-led and good for being caring and responsive. Consequently the practice was rated as inadequate overall.

The specific concerns identified were:

• There was not always evidence of learning from significant events and not all staff were involved in significant event discussion.

• Satisfactory recruitment checks had not been undertaken for all staff prior to employment.

• The practice’s supply of oxygen had expired.

• Systems and processes did not operate effectively to ensure that patients were safeguarded from abuse.

• Infection control risks were not adequately assessed or addressed.

• Medicines were not always managed safely in that high risk medicines were not always monitored appropriately, two of the practice’s Patient Group Directions had expired, emergency medicines and prescriptions were not stored securely and vaccines were not being monitored appropriately.

• The practice had not complied with the recommendations in their last fire risk assessment.

• Partners in the practice had failed to ensure that effective systems were in place for the management of test results and to ensure a failsafe system for referrals for urgent tests and assessments.

• Some practice policies were incorrectly dated, did not contain all requisite information, were not regularly reviewed and were not easily accessible to staff.

• There was no system to ensure all staff were regularly appraised.

• Training had not been completed by all staff.

• There were insufficient numbers of clinical staff.

The practice provided the Care Quality Commission (CQC) with an action plan within 48 hours of the inspection which detailed the action the practice intended to rectify some of the concerns identified on the day of the inspection.

Due to delay on the part of CQC in producing a finalised report from the inspection undertaken on 26 July 2016 and the significant patient safety concerns identified, we undertook a focused inspection of the practice in order to ascertain whether or not the provider had taken the necessary action to address the concerns raised. The current overall rating for this practice is an aggregation of the ratings for caring and responsive in the report from the inspection undertaken on 26 July 2016 and the rating for safe, effective and well led in this inspection report which focused on these key questions. You can read the report from the first comprehensive inspection by selecting the ‘all reports’ link for Drs Masterton, Thomson, Bolade & Otuguor on our website at www.cqc.org.uk.

Had CQC found that the practice were still inadequate for any key question during this inspection the service would have been placed in special measures for a period of six months after which time a further inspection would have been undertaken to see if sufficient improvement had been made.

An announced focused inspection was undertaken on 1 December 2016. This report focuses on the action that the practice has taken to address the concerns identified during our initial inspection.

Overall the practice is rated as requires improvement. Specifically, following the focussed inspection we found the practice to be requires improvement for providing safe, effective and well led services. This recognises the significant improvements made to the quality of care provided by this service. Our key findings across all the areas we inspected were as follows:

• There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.

• The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse although most staff had yet to receive child and adult safeguarding training.

• The practice had undertaken appropriate recruitment checks for newly appointed staff but had yet to receive a Disclosure and Barring Service check for the practice healthcare assistant.

• The practice had introduced effective systems to manage results from secondary care and there was evidence of regular multidisciplinary meetings.

• The practice had not implemented the recommendations from their fire risk assessment and there was no effective lead for infection control. All other infection control concerns had been addressed.

• There were sufficient numbers of staff to meet patient need.

• Concerns around high risk drug monitoring had been addressed. However, the practice healthcare assistant was administering medicines in line with Patient Group Directions and not Patient Specific Directions or prescriptions in accordance with current legislation.

• The practice had effective systems in place to deal with emergencies.

• Most staff had still not been appraised within the last 12 months.

• Policies had been updated, contained all necessary information and were accessible to all staff.

The areas where the provider must make improvement are:

• Ensure that medicines administered by a healthcare assistant are done so in accordance with a valid Patient Specific Direction.

• Ensure that the practice has an infection control lead that is adequately trained for the role and that all staff are aware of this person.

• Ensure all staff have completed all necessary training in accordance with current legislation.

• Ensure that all staff are regularly appraised.

The areas where the provider should make improvement are:

• Review the high exception rates for those with atrial fibrillation and chronic obstructive pulmonary disease to ensure that all exemptions are appropriate.

• Continue efforts to ensure that staff feel valued.

The findings of this report should be read in conjunction with the findings detailed in the report from our initial inspection conducted on 26 July 2016

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We reviewed the information available to us about Drs Masterton, Thomson, Bolade & Otuguor on 21 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.