This practice is rated as Requires improvement overall and rated as good for providing effective, caring, and well led services and requires improvement for providing safe and responsive services.

This is the fourth inspection of The Haverhill Family Practice. At our previous inspection in September 2017, the practice was rated as good overall and for providing safe, caring, responsive and well led services and requires improvement for providing effective services. We undertook a focused inspection 31 May 2017 to follow up on the enforcement that we had issued as part of our January 2017 inspection. At our previous inspection January 2017, the practice was rated inadequate overall and for safe, effective and well led services. The practice was rated as requires improvement for providing caring and responsive services. The practice was placed into special measures.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Haverhill Family Practice on 23 October 2018 to follow up on the improvements required that were identified in our inspection in September 2017.

At this inspection we found:

• 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 system and processes to ensure patients attended annual recalls had been improved. The practice had ensured clinical oversight for monitoring the quality and outcome framework and patient exception reporting.
• We found that not all patients taking high risk medicines had received their monitoring in a timely manner. This had been identified as a concern in our report for the inspection undertaken in January 2017.
• The practice had employed additional clinical staff and had used a wider skill mix to meet patient demand.
• All staff we spoke with told us that the practice had sustained the strong leadership to ensure they offered patient centred care.
• Reception staff had been trained as care navigators to ensure patients saw the right person at the right time.
• The practice had embeded a programme of audits to ensure safety and quality was monitored and improvements made where necessary.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The GP patient survey data showed some areas of improvement but some areas had declined further and patients found they experienced difficulties in getting through on the phone. The low patient satisfaction rates had been highlighted in our previous reports.
• The practice had undertaken their own practice survey in April 2018 and had implemented changes to improve areas of patient satisfaction.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements is:

• 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.

The area where the provider should make improvements is:

• Improve the system and process to ensure all patients medicines reviews are undertaken in a timely manner.

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 Haverhill Family Practice on 17 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Haverhill Family Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 26 September 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• The practice demonstrated improved clinical leadership to assess, monitor, and improve the quality and safety of the services provided in the carrying on of regulated activities (including the quality experience of service users in receiving those services) and is now good.
• Appropriately qualified persons had undertaken fire safety, health, and safety risk assessments. The practice had developed an action plan to ensure all actions identified were completed in a timely way.
• The systems and processes in place for reporting and recording significant events had been improved and are now good and learning was shared with the practice team.
• The system for receiving and acting on alerts from the Medical and Healthcare products Regulatory Agency (MHRA) had been improved.
• There were significant improvements in the management of patients who were taking medicines which required closer monitoring.
• The practice had improved the management of infection prevention and control.
• The practice had reviewed the national patient survey data, compared the findings to their own survey data, and used the information to plan and make improvements.
• Information about services and how to complain was available to patients and the practice recorded all incidences however minor.
• The practice demonstrated that they had implemented a programme of audits to evaluate their performance and to ensure the governance systems remained effective, delivered improvement in outcomes for patients, and ensured a good quality of record keeping.
• Role specific training was undertaken for new administrative staff and formal induction processes had been implemented.
• Patients said they found it relatively easy to make an appointment with a named GP although there could be a wait and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Practice staff felt supported by the management team and the GPs. The practice proactively sought feedback from staff and used the PPG survey for feedback from patients.
• The provider was aware of and complied with the requirements of the duty of candour.
• Patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.
• The practice had implemented systems to pro-actively identify patients who were carers to ensure they received appropriate support.

The areas where the provider should make improvement are:

• Continue to monitor the improvements made to the systems and processes to ensure that patients receive follow ups that are appropriate and in a timely manner.
• Continue to address all actions identified in the risk assessments that had been undertaken.
• Continue to assess and ensure improvement to national GP patient survey results relating to patient satisfaction for access.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

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 Haverhill Family Practice on 17 January 2017. The overall rating for the practice was Inadequate. Breaches of legal requirements were found and after the comprehensive inspection we issued the following warning notice:

• A warning notice informing the practice that they were failing to comply with relevant requirements of the Health and Social Care Act 2008. As a result, the practice was required to become compliant with specific areas of Regulation 17: good governance of the HSCA (RA) Regulations 2014, by 31 May 2017.

The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Haverhill Family Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 31 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 17 January 2017. This report only covers our findings in relation to those requirements.

Our key findings were as follows:

• The practice demonstrated improved clinical leadership in order to assess, monitor, and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality experience of service users receiving those services).

• Appropriately qualified persons had undertaken fire safety and health and safety risk assessments. The practice had developed an action plan to ensure all actions identified were completed in a timely way.

• System for receiving and acting on alerts from the Medical and Healthcare products Regulatory Agency (MHRA) had been improved.
• There were improvements in the management of medicines which required closer monitoring.

• The practice had reviewed the national patient survey data, compared the findings to their own survey data, and used the information to plan improvements.

• The practice demonstrated that they had implemented a programme of audits to evaluate their performance and to ensure the governance systems remained effective, delivered improvement outcomes for patients, and ensured the quality of record keeping.

In addition the provider should:

• The provider should continue to monitor the newly implemented systems and process to ensure improvements to quality and safety are made and monitored. For example, the newly implemented programme of audits, the management and monitoring of safe prescribing, and the management of safety alerts.

This service was placed in special measures in April 2017 and is due to be inspected again within six months of the publication of the final report. When we re-inspect, we will also look at whether further progress has been made to complying with Regulation 17: good governance HSCA (RA) Regulations 2014, including specific areas for improvement such as, management of fire safety and health and safety, management of safety alerts and medicines management. We will also look at whether further progress has been made to complying with Regulation 16: receiving and acting on complaints HSCA (RA) Regulations 2014.

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 Haverhill Family Practice on 17 January 2017. Overall the practice is rated as inadequate.

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

• There was a clear management structure, however we found there was an overall lack of clinical leadership at the practice. The clinicians lacked awareness around, and had not reviewed, their exception reporting in relation to the Quality and Outcomes Framework (QOF) which was high in some areas. Data management was overseen by administrative staff.
• Governance systems in place were insufficient to ensure that patients and staff were kept safe from harm. The practice had not carried out fire risk assessments or health and safety risk assessments and had not completed annual infection control audits.
• There was a system in place for reporting and recording significant events, but this needed to be improved. On the day of the inspection we reviewed several entries that had not been discussed at meetings and where no learning outcomes or action plans had been recorded.
• The system in place for managing patient safety and medicine alerts was not effective. Improvements were needed to ensure that patients taking high risk medicines were regularly monitored.
• There was a lack of clinical audits carried out to ensure that quality improvements were made and monitored.
• Information about services and how to complain was available on the practice website, but there were no complaints leaflets or information available to give to patients attending the surgery.
• Role specific training was undertaken for new administrative staff, but there was no formal induction process. Competency was assessed at three and six monthly intervals.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Practice staff felt supported by management and the GPs. The practice proactively sought feedback from staff and used the PPG survey for feedback from patients.
• The provider was aware of and complied with the requirements of the duty of candour.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice did not pro-actively identify patients who were carers to ensure they received appropriate support.

We saw an area of outstanding practice

• The practice employed two emergency care practitioners (ECPs) and utilised their experience and knowledge to deal with emergencies. If for any reason the duty doctor was not able to respond immediately to an emergency call in the practice or at the patient’s home, the ECPs were skilled and equipped to deliver emergency care. This ensured that patients had access to immediate care and in some cases saved an ambulance from being called. In addition they provided training to practice staff and patients, giving them the skills and confidence to deal with an emergency.
• The practice offered six weekly, one hour education sessions to patients which included anaphylaxis, cardiopulmonary resuscitation (CPR) and choking. These sessions were undertaken by the ECPs and a GP was present at each session. The practice advertised these sessions in the waiting rooms and on their website. Eight patients were allowed to attend each session which were interactive, with patients taking part in CPR. The ECPs ran through possible scenarios, gave a demonstration, handouts and information leaflets and answered questions once the demonstration had finished. Patient feedback sheets were completed at the end of each session.

The areas where the provider must make improvement are:

• Ensure the practice is able to provide evidence of actions taken in response to relevant alerts and updates issued from the Medicines and Healthcare products Agency (MHRA) and through the Central Alerting System (CAS).
• Ensure fire risk assessments and health and safety risk assessments are undertaken for both practice sites and ensure any improvement areas identified are actioned and recorded.
• Ensure there is an effective process in place to monitor the prescribing of high risk medicines.
• Implement effective governance systems at the practice to ensure that a high quality and safe service is being provided to patients.
• Ensure that the practice maintains complete records of complaints with learning outcomes and action plans identified and that information on how to complain is made available to patients at both sites.
• Ensure the practice acts on the feedback from the national patient survey to improve the quality of the services at the practice.
• Ensure significant events are recorded and discussed at practice meetings, and learning outcomes and actions plans undertaken and recorded.
• Implement an ongoing clinical improvement programme to drive improvements in patient outcomes.

The areas where the provider should make improvement are:

• Proactively identify patients who are carers to ensure they receive appropriate support.
• Ensure the practice undertakes infection control audits at both sites.
• Undertake a clinical review of exception reporting of patients from Quality Outcomes Framework (QOF) data sets in order to ensure that this is done reasonably and appropriately.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice