This practice is rated as Good overall. At our previous inspection on 22 June 2017 the practice was rated as inadequate and placed into special measures this followed our first inspection on 12 April 2016 where the practice was rated as requires improvement.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

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 Forest Hill Group Practice on 8 February 2018. This inspection was undertaken as the service was rated as inadequate at our previous inspection and placed into special measures. At our last inspection on 22 June 2017 the practice was rated as inadequate for providing services that are safe and well led and requires improvement for effective. We identified breaches of regulations 12 and 17 of the Health and

Social Care Act 2008 (Regulated Activities) Regulations 2014. Breaches related to the practice failing to adequately assess and mitigate risks associated with infection control, the management of medicines and equipment, and recruitment and monitoring. In addition, the practice’s chaperoning procedures did not ensure patients were kept safe. The practice had also not reviewed high rates of exception reporting and did not have adequate systems in place to follow up patients following a cervical screening test.

Prior to that we inspected the service on 12 April 2016 and rated the service requires improvement for providing care that was safe, effective and well led. We identified breaches of regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Breaches related to deficiencies in safety systems for the management of medicines, infection control, recruitment and training. There was also limited evidence of quality improvement work, lack of effective systems relating to the management of significant events and a lack of effective policies and processes. Staff also had not received an annual appraisal and there was a lack of mechanisms to ensure staff felt supported.

At this inspection we found:

That the concerns from our previous inspection had all been addressed. The practice had taken action not only to address the concerns identified on our last inspection but also to improve leadership and management to ensure that improvements made were embedded and sustained.

For example:

• The practice now 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.

• Staff treated patients with compassion, kindness, dignity and respect.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

However:

• Although national patient survey scores were largely positive in respect of access, some patients that we spoke with on the day of the inspection found it difficult to access routine appointments or get through on the telephone and the next available routine GP appointment was four weeks. The practice had recently recruited four additional salaried GPs with a view to improving both access and continuity of care for patients and was in the process of upgrading their phone systems.

• The practice had not met Public Health England targets related to childhood immunisations and cervical screening. Public Health England data for targets related to smoking cessation also indicated that the practice was performing below local and national averages though unverified data provided by the practice indicated that they were meeting this target.

The areas where the provider should make improvements are:

• Work to monitor and improve access to routine appointments and to monitor and improve telephone access.

• Work to improve the care of patients with rheumatoid arthritis and fragility fractures, increase the uptake of childhood immunisations and review higher than average exception reporting rates.

• Improve systems and processes that support the identification and record keeping in respect of patients with caring responsibilities to enable appropriate support and signposting to be provided.

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 Forest Hill Group Practice on 12 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report from the inspection undertaken on 12 April 2016 can be found by selecting the ‘all reports’ link for Forest Hill Group Practice on our website at www.cqc.org.uk.

As a result of our findings from this inspection CQC issued a requirement notice for the identified breaches of Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Specifically we found concerns related to the management of significant events, medicines and risks associated with staffing and infection control, absence of staff training and appraisal, issues around governance and there was little evidence of quality improvement work being undertaken.

This inspection was undertaken within 12 months of the publication of the last inspection report as the practice was rated as requires improvement for three of the key questions; are services safe?, are services effective? and are services well led?, and so requires improvement overall. This was an announced comprehensive inspection completed on 22 June 2017. Overall the practice is now rated as inadequate.

Our key findings at this inspection were as follows:

• The practice had a system in place for reporting significant events. Events were discussed at practice meetings but discussions with some staff indicated that learning was not embedded and non-clinical staff in the practice did not know the process for reporting significant events.
• The systems and processes used to assess and address risks to patient safety were not always effective. The practice had completed fire and health and safety risk assessments in June 2017 but had not implemented the actions. Infection control risks had been assessed but not all had been addressed. Staff were not chaperoning in accordance with best practice and guidance and there was no evidence of the correct level of safeguarding training for one of the GPs in the practice. The practice had not completed all necessary recruitment checks for staff.
• The processes around medicines management did not ensure that were kept safe. Not all Patient Group Directions had been completed correctly, prescriptions were not stored securely and their use was not effectively monitored. We found expired syringes with the practice’s emergency supplies and not all recommended emergency medicines were present nor was their an assessment of the risk of not having these medicines.
• Some staff had not completed essential training in accordance with current legislation and guidance including infection control, information governance, fire and basic life support training.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. However, some patients that we spoke with on the day expressed dissatisfaction with the attitude of reception staff.
• Information about how to complain was available and we saw improvements were made to the quality of care as a result of complaints and concerns.
• Health promotion leaflets and information on local services were available.
• Feedback regarding access was mixed. Though most feedback showed that patients could access appointments when needed, some patients we spoke with said they found it difficult to make an appointment.
• Though there was a leadership structure in place this was not always effective.
• The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.

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

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients.

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

In addition the provider should:

• Advertise translation services in the reception area.

• Improve systems and processes that support the identification of patients with caring responsibilities to enable appropriate support and signposting to be provided.

• Consider ways to improve patient satisfaction with access to appointments and the service provided by the practice’s reception team.

I am placing this service in special measures. 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.

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

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 Forest Hill Group Practice on 12 April 2016. Overall the practice is rated as requires improvement.

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. However, reviews and investigations were not thorough enough and it was not always clear what action had been taken to address concerns affecting individual patients.

• Risks to patients were not always well managed. For example the practice was not regularly monitoring the professional registrations of clinical staff, vaccination fridge temperatures were not monitored on a daily basis and there was no evidence of any intervention on the occasions when the temperature was above the optimum. Additionally there was no evidence of an infection control audit, upstairs treatment rooms were carpeted, prescriptions and medicines were not always securely stored and there were expired medicines and clinical equipment on the premises.

• Some mandatory staff training had not been completed including infection control and safeguarding.

• Data showed patient outcomes were comparable to local and national averages except in respect of the management of diabetic patients where the outcomes were lower. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance or improving patient outcomes.

• The majority of patients said they were treated with compassion, dignity and respect and felt cared for, supported and listened to.

• Urgent appointments were available on the day they were requested; however, we saw evidence that a number of patients had expressed dissatisfaction with the appointment system in the past; particularly advance appointments. We were told that this was a result of historic staffing issues. However the practice had recently recruited new staff to increase the availability of appointments.

• The practice had a number of policies and procedures to govern activity though some staff were unaware of the practice’s safeguarding policy and we saw no evidence that the significant event process was being followed.

• The practice sought feedback from patients and had a patient participation group who were enthusiastic about making improvements to the practice; however, the group had begun formally meeting in November 2015 after having not met for 13 months.

The areas where the provider must make improvements are:

• Ensure that significant event procedures are consistently applied and that action is taken to address the concerns raised.

• Ensure that the practice has a comprehensive governance framework and the policies are implemented consistently and regularly monitored.

• Complete regular infection control audits and take action to address any areas of non-compliance with infection prevention and control guidance.

• Ensure that there are sufficient numbers of staff to meet patient demand, provide a comprehensive range of services and ensure effective administrative oversight and direction.

• Ensure that no staff are asked to undertake duties in which they are not competent.

• Replace the carpeting in all treatment rooms.

• Ensure that all medicines and prescriptions are securely stored.

• Ensure that the cold chain procedure is adhered to in relation to the storage of medicines.

• Ensure systems are in place to monitor the expiration dates of medicines and equipment.

• Ensure that all staff receive appropriate mandatory training.

• Ensure recruitment and monitoring arrangements include all necessary employment checks for all staff.

• Carry-out quality improvement work including clinical audits to improve patient outcomes and continue to work to improve the management of patients with diabetes so that outcomes reflect national and local averages.

  In addition the provider should:

• Continue to review the practice’s appointment system with a view to improving access to advance appointments.

• Review support arrangements for staff and ensure that appraisals are completed annually and that there is a formalised induction process in place for all new members of staff

• Consider having a formalised business plan in place.

• Advertise translation services in the reception area.

• Continue to work with and develop the practice’s patient participation group.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice