This practice is rated as Good overall. (Previous rating February 2015 – Overall Good; Safe was rated Requires Improvement but with no breach of regulations)

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 at Evergreen Surgery Limited on 27 September 2018 as part of our inspection programme.

• 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 had systems to keep patients safe and safeguarded from the risk of abuse. The practice maintained a register of children and adults assessed as vulnerable and their care was discussed at weekly clinical meetings.
• 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 a strategy for monitoring patients with long term conditions, which ensured all patients were offered an annual structured review.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had made improvements to the telephone system which allowed the practice to expand the responsiveness of the system during peak times.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Introduce a process to monitor the usage of blank prescription stationery.

• Review the effectiveness of systems in place to monitor the health of patients prescribed with high-risk medicines.

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 an announced comprehensive inspection at Evergreen Surgery Limited on 3 February 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 older people, people living in vulnerable circumstances, people with long term conditions, families, children and young people, working age people (including those recently retired and students) and people experiencing poor mental health (including people with dementia).

It was rated as requires improvement for providing safe services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Nursing staff administered childhood vaccines under Patient Group Directives (PGDs - written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment). However, a locum nurse working at the practice and giving vaccinations had no such authorisation and was therefore not legally able to give these injections.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 areas of outstanding practice:

• In 2013, the practice identified that cervical screening and childhood immunisation rates were lower than the locality average. It was felt that the low immunisation rates were due to cultural reasons and a lack of awareness. We noted that the practice’s local population was diverse and also that it had a high percentage of people aged under eighteen. Two coordinator posts were created (which included an element of community outreach) and we noted that both post holders were multi-lingual; recognising the diverse nature of the population. The practice told us that these posts had had a positive impact.
• For example, prior to the creation of the posts, the practice did not meet Department of Health 90% immunisation target for either two or five year olds. Following the introduction of the immunisation co-ordinator, we were told that the practice now routinely achieved immunisation targets for two year olds and was close to reaching the target for five year olds. The figures for the last complete quarters were 93.1% for two year olds and 84.1% for five year olds. For the first quarter of 2013, the equivalent figures had been 88.7% and 81.1% respectively. We were also told that in 2013, only 63% of women in the target age group had undertaken cervical screening. Latest available data showed that the practice’s performance was 79.8%.
• After each consultation, patients were sent an SMS text asking them to rate their consultation. This data was collated and discussed at quarterly meetings.

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

Importantly the provider should:

• Ensure policies and procedure related to the recruitment of staff are fit for purpose.
• Ensure that all necessary pre-employment checks are retained on file for staff.
• Ensure that signed and valid PGDs are on file for all nursing staff.

• Undertake annual appraisals for practice nurses; to ensure that progress is reviewed, targets agreed and training needs identified.
• Consider translating patient information leaflet in reception into local community languages.
• Consider introducing building signage in local community languages.
• Ensure that all non clinical staff are up to date regarding basic life support training.
• Ensure that signed and valid PGDs are on file for all nursing staff.
• Ensure that the practice’s emergency drugs protocol includes a list of the contents of the emergency trolley.
• Ensure that its medicines management policy includes a protocol for staff to follow in the event that the “cold chain” is disturbed (the cold chain refers to the continuous maintenance of low temperatures required for some medicines such as vaccines).
• Consider introducing a systematic programme of clinical audit to drive improvements in patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Our inspection of 24 July 2013 found that the service did not always treat patients with consideration and respect, they were not given information regarding the treatments provided by the practice and the systems the service had to monitor and improve the quality of treatment that patients received were not always effective. At this inspection we spoke with ten patients who told us that staff treated them with respect and that they understood what treatments the practice provided. Patients comments were, "I'm treated very well," "both the reception staff and general practitioners are very helpful," and "I can tell them if I have a problem and they help me." Patients told us that they were fully involved in decisions about their care and treatment. The registered manager told us that information about the practice and the treatments it provided was now available in number of community languages (for example, Turkish). The practice's website also provided this information and offered patients a way of booking appointments online. This meant that the service responded to patients complaints, comments and suggestions.

Patients told us that they could get to see a general practitioner when they needed to. One patient said, "the staff here, both at reception and the general practitioners are very helpful and nice." We looked at three patient's records and these showed that each treatment provided by the general practitioner was recorded. General practitioners could now book their own follow-up appointments and patients could ask for a particular general practitioner when pre-booking their appointments. The registered manager explained that patients could now book double appointments which would give them greater time to discuss their needs with general practitioners. This meant that patients whose first language was not English and those patients with complex medical needs had more time with general practitioner, so that they received the treatment they required.

We found that the provider had introduced a number of ways in which patients could be involved in the monitoring of the quality of the service and make suggestions on how the service could be improved. The majority of patients spoken with said that the quality of the service had improved. In particular they highlighted that it had become easier to make appointments and that staff were more responsive to their needs. One person's comments were typical when they said, "the staff here listen to what I say." Complaints forms were also available, and posters telling patients about how they could complain had been put up in the main waiting area of the practice.

Patients told us that it was very difficult to make appointments to see a doctor when they needed to. Patients told us that they were not able to see the same GP at each appointment, which meant they felt that GPs did not have an understanding of their needs.

Patients told us that they were not responded to in a professional or sensitive manner by the reception staff and described reception staff as “unhelpful”, "rude" and "unprofessional." The majority of patients spoken with felt they were not fully involved in decisions about their care and treatment.

There were arrangements in place for dealing with medical emergencies and policies and procedures were in place for staff to follow should they have concerns about the safety of children and vulnerable adults.

All patients spoken with said that the surgery was clean and measures to prevent infection were in place.

The surgery's quality assurance systems were not effective in improving patient satisfaction with the quality of the service and patients felt that their concerns would not be listened to.

Records were kept securely and could be located promptly. Patients' medical records were accurate and fit for purpose.