This practice is rated as Requires Improvement overall. (Previous rating published 10 August 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Hawthorn Drive Surgery on 9 October 2018. The practice was previously inspected on 14 November 2016 and was rated as inadequate for providing safe, effective and well led services, requires improvement for providing caring services and good for providing responsive services. Overall the practice was rated as inadequate. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 December 2016 for regulation 17 (good governance). They were also given a requirement notice for regulation 12, safe care and treatment. The practice was placed into special measures for six months. A focussed inspection was undertaken on the 16 February 2017, to check on improvements detailed in the warning notice issued on 13 December 2016, following the inspection on 14 November 2016. They had complied with the warning notice. A comprehensive inspection was undertaken on 17 July 2017. The practice was rated good overall and good for all domains with the exception of effective, which was rated requires improvement. The practice was taken out of special measures. This inspection was undertaken to check that improvements had been sustained because the practice had gone from being in special measures to being rated good overall.

At this inspection we found:

• There was an effective system for recording and reporting of significant events and complaints. A process for sharing of learning and ensuring that actions had been completed had been established and this was embedded.
• Systems were in place to keep people safe, however they were not always followed. The practice were not able to evidence that three clinicians and one non-clinician had a Disclosure and Barring Service (DBS) check completed by the practice, or assurance from NHS England, that an appropriate DBS had been completed. References had not been obtained for two nurses before they commenced employment at the practice. The vaccination history of staff had not been obtained, except for Hepatitis B status. A process was not in place to check the professional registration of staff on an ongoing basis. Following the inspection, the practice advised that they had established a system to check this.
• Training which was deemed mandatory had not been completed by all staff. This included training for safeguarding children and vulnerable adults, basic life support, infection control and fire safety.
• Arrangements were in place for infection prevention and control, however the checks of daily cleaning completed by clinical staff were not always completed. The practice’s policy advised that sharps boxes should be changed every three months. We found one sharps box which was dated April 2018 and one sharps box which had not been dated.
• An effective system was in place to review and act on safety alerts and this had been embedded.
• Some improvements had been made to ensure patients were coded according to their diagnosis and that treatment was appropriate. A system of recall for patients who required monitoring had been embedded which included the implementation of a lead GP, other clinical staff and administration support. However, the practice’s performance on quality indicators for people with long term conditions, for example diabetes and COPD was significantly lower than the CCG and England averages. They also had a significantly higher than average exception rate for five of the seven QOF mental health indicators.
• Patients diagnosed with cancer were not all reviewed appropriately and only 18 out of 66 patients with a learning disability had received a health review.
• The practice undertook audits, for example to identify areas of patient need, and to monitor workload to inform appropriate staffing levels. There was evidence of clinical audit, with some two cycle audits which had a positive impact on the quality of care for patients.
• The practice worked with external agencies and services to meet the needs of patients. Social services and the Citizens Advice Bureau (CAB) held a drop-in clinic at the practice every week. Multidisciplinary meetings were held, minuted and actions from these had been documented in the patient’s medical record. However, not all patients diagnosed with cancer had been reviewed.
• Staff involved and treated patients with compassion and kindness. Patients said they were treated with dignity and respect and were involved in their care and decisions about their treatment
• In general, patients found the appointment system easy to use and reported that they could access care when they needed it.
• Staff reported they were supported by the management team and were happy to work in the practice.
• Leaders had the capacity and skills to deliver high-quality, sustainable care, however effective systems were not always in place to ensure this was provided.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider

should

make improvements are:

• Review and improve systems for managing infection prevention and control, particularly the management of sharps boxes and the documentation of in house cleaning.
• Continue to develop the system to include the review of patients who are identified as being frail.
• Complete the hard wiring test of the premises.

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 Hawthorn Drive Surgery on 14 November 2016. The practice was rated as inadequate for providing safe, effective and well led services, requires improvement for providing caring services and good for providing responsive services. Overall the practice was rated as inadequate. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 December 2016 for regulation 17 (good governance). They were also given a requirement notice for regulation 12, safe care and treatment. The practice was placed into special measures for six months. A focussed inspection was undertaken on the 16 February 2017, to check on improvements detailed in the warning notice issued on 13 December 2016, following the inspection on 14 November 2016. Hawthorn Drive Surgery had complied with the warning notice, however further improvements were required. The full comprehensive reports on the 14 November 2016 and 16 February 2017 inspections can be found by selecting the ‘all reports’ link for Hawthorn Drive Surgery on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Hawthorn Drive Surgery on 17 July 2017, following the period of special measures. Overall the practice is rated as good.

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

• There was an effective system for recording and reporting of significant events. A process for sharing of learning and ensuring that actions had been completed had been established and we saw evidence of this in practice.

• Clinical staff had signed up to receive Medicines & Healthcare products Regulatory Agency (MHRA) alerts and National Institute for Health and Care Excellence (NICE) guidance and these were shared within the practice. A system had been established and implemented to review and act on MHRA alerts, which included alerts which may remain relevant.
• Risks to patients and staff were assessed and well managed, including those related to health and safety and infection control. Safe practices were in place in relation to the cleaning of spilt body fluids.
• Improvements had been made to ensure patients were coded according to their diagnosis and that treatment was appropriate. This work needed to be further embedded in practice, to ensure effective care and treatment for all patients.

• A system of recall for patients who required monitoring had been established which included the implementation of a lead GP, nurse and administration support.

• Five two cycle clinical audits had been completed, which showed improvements. These were limited to patient coding and medicine issues. The practice could not yet evidence a programme of completed audits that had been re-run to monitor and improve outcomes on the quality of care for patients.

• Multidisciplinary meetings had been held, were minuted and actions from these had been documented in the patient’s medical record. The practice had established good working relationships with other agencies. Social services and the Citizens Advice Bureau (CAB) held a drop in clinic at the practice every week.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients said they were treated with dignity and respect and were involved in their care and decisions about their treatment.

• Two thirds of the patients we spoke with or received comments from found it easy to make an appointment. Four patients reported that there was often a wait for the telephone to be answered in the morning. Appointment requests for children, vulnerable patients, the elderly and those with palliative care needs were prioritised.

• Information about how to complain was available and easy to understand. Improvements were made as a result of complaints, with a process for the sharing of learning and checking that actions identified had been completed.

• A foundation for effective governance had been established and maintained. Meetings were held and identified actions and responsibility for completion documented.

The areas where the provider should make improvement are:

• Maintain evidence of training for locum GPs.

• Review the arrangements for responding to periods of high patient activity in the reception area. Continue to review the arrangements for answering the telephone to improve patient’s satisfaction.

• Formally review the work undertaken by advanced nurse practitioners to obtain assurance of the quality of their work.

• Continue the current programme of quality improvement including clinical audits to monitor the effectiveness of new systems and processes.

• Continue the work to ensure that all patients are appropriately coded.

This service was placed in special measures in December 2016. 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 Hawthorn Drive Surgery on 14 November 2016. Improvements were required and a warning notice was served in relation to ensuring processes were in place for effective governance. The practice was rated as inadequate and was placed in special measures. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Hawthorn Drive Surgery on our website at www.cqc.org.uk. 

We undertook a focused follow up inspection on 16 February 2017 to check that the practice had taken urgent action to ensure they met the the required improvements for good governance. This report only covers our findings in relation to the warning notice. A comprehensive inspection will be carried out within six months to check that the practice had followed their action plan for the other issues identified at the previous inspection and to confirm they meet legal requirements.

Our key findings were as follows:

• There was an effective system for recording and reporting of significant events. A process for sharing of learning and ensuring that actions had been completed had been established, but needed to be embedded into practice. This was the same for complaints.
• Clinical staff had signed up to received Medicines & Healthcare products Regulatory Agency (MHRA) alerts and National Institute for Health and Care Excellence (NICE) guidance. These were shared within the practice. A process had been established to review and act on MHRA alerts. Some alerts from 2016 had been acted upon but two which had been identified by the practice as relevant had not yet been acted upon.
• Multi-disciplinary meetings had been scheduled and one meeting had taken place. Patient records had been updated to reflect the discussion and agreed actions.
• The practice had established an agreed coding system for patients’ conditions and care and treatment needs. Improvements had been made to ensure patients were coded according to their diagnosis and that treatment was appropriate. However we found two examples of where patients had been coded inaccurately.
• A system of recall for patients who required monitoring had been established which include a lead GP, nurse and administration support and was due to be implemented imminently.
• A foundation for effective governance had been established. This included lead roles for GPs and lead clinical areas for GPs, nurses and administration staff. A range of meetings had also been established, scheduled and at least one meeting had occurred, which had been minuted.

However, there were areas where the provider needed to continue to make improvements.

Importantly, the provider must:

• Ensure that Medicines & Healthcare Regulatory Agency (MHRA) alerts identified as needing to be actioned are completed and the changes affected to ensure patients are safe and an effective process for checking that National Institute for Health and Care Excellence (NICE) guidance has been implemented appropriately.

• Continue to maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.
• Ensure that annual health reviews are offered for those patients with a learning disability who have not yet received one and that coding for patients with a learning disability is accurate.

The areas where the provider should make improvements are:

• Continue to record agreed actions from meetings where patients are discussed and reviewed, to evidence working in partnership with other relevant agencies and ensure patients’ records reflected information shared to keep patients safe.
• Continue to embed the newly formed system of governance and ensure it is effective.

Hawthorn Drive Surgery had complied with the warning notice, however further improvements are required. These will be reviewed at the comprehensive inspection which is due when the special measures period ends.

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 Hawthorn Drive Surgery on 14 November 2016. Overall the practice is rated as inadequate.

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

• There was an effective system for recording and reporting of significant events. However the process for the sharing of learning and ensuring that actions had been completed was not effective.
• The patients and practice staff were at risk of harm, as the practice had not undertaken the recommended action from the Health and Safety and Legionella risk assessment to ensure that they would be kept safe. Non-clinical staff were expected to clean body fluids without their Hepatitis B immunity being checked and not all staff had completed infection control training.
• The process for ensuring that MHRA alerts were actioned for patients affected was not adequate.
• The practice could not evidence a programme of completed audits that had been re-run to monitor and improve outcomes for patients or to ensure quality of record keeping. Inaccurate coding had been identified as an issue in March 2015 and had not been resolved at the time of the inspection.
• Some areas of the practice performance were insufficiently supported to ensure safe and effective care and treatment for patients. For example, data from the quality and outcome framework was significantly lower than the CCG and national averages in some areas and the exception reporting was significantly higher than the CCG and national averages in many areas.
• The practice told us that multidisciplinary meeting were held to discuss and review vulnerable patients, the elderly, children with safeguarding needs and patients with palliative care needs. We saw agendas for these meetings, but there were no minutes to ensure that any relevant information was shared with the appropriate clinical staff. We did not see any evidence that the actions from these meetings were recorded in patient’s notes.
• Patients said they 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. However there was no formal process for the sharing of learning and checking that actions identified had been completed.
• The majority of 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. Appointment requests for children, vulnerable patients, the elderly and those with palliative care needs were prioritised.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had established good working relationships with other agencies. The Citizens Advice Bureau (CAB) held a drop in clinic at the practice on Thursdays.

The areas where the provider must make improvement are:

• Ensure there is an effective process for sharing and checking that actions have been completed in relation to patient safety alerts, for example MHRA alerts and NICE guidance.
• Ensure there is an effective process for checking that agreed actions identified as a result of significant events and complaints have been implemented.
• Review the arrangements for cleaning of body fluids by ensuring they meet the requirements as detailed in the Health and Social care Act (2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance.
• Ensure that the actions from the Legionella risk assessment and Health and Safety risk assessment undertaken in July 2016 are completed.
• The practice must record agreed actions from meetings to evidence their working in partnership with other relevant agencies and ensure patients records reflected information shared to keep patients safe.
• Ensure that an accurate, complete and contemporaneous record is maintained for every patient.
• Ensure there is clinical leadership capacity to deliver all improvements.
• Ensure that the CQC registration of the practice and Registered Manager is up to date.

The areas where the provider should make improvement are:

• Maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.
• Agree and implement a process for checking uncollected prescriptions, ensuring that GPs are aware of patients who may not be compliant with their medicines.
• Review the recording and coding of medical records to ensure accurate and reflective care and treatment of patients.
• Implement a practice specific safeguarding adults and children policy.
• Ensure that annual health reviews are offered for those patients with a learning disability who have not yet received one.
• Ensure that a copy of the business continuity plan is kept off site.
• Ensure that internal audits of the cleaning are undertaken.
• The practice management should implement systems to give oversight and assurance that staff receive all training appropriate to their roles and needs.
• Review systems and process to ensure that complaints and feedback are managed effectively and safely. Minutes of meetings should contain sufficient detail to ensure shared learning by practice staff.
• The practice should seek to increase the number of patients who attend for a cervical screen.
• Chaperones should themselves record any duties carried out on the practice system.

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

During our inspection we saw reception staff were polite and welcoming to people visiting Hawthorn Drive Surgery. We spoke with a parent who said, "The doctor is really good with my children, they talk to them on their level, they are really friendly."

One person we spoke with said, “I am helped to manage my own care and things are explained to me really well.” We saw evidence that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

We saw that the administrative staff produced repeat prescriptions within the guidelines set for staff at the surgery. All prescriptions were generated from the computer and the prescribed medication, including repeat medication were clearly documented.

One person said “It’s easy to get an appointment. I ring up and see who is available.” Another person said, “The service over the counter is very good but I can’t always get an appointment with my GP.”

One nurse we spoke to said, “I asked to do the nurse prescribing course and they agreed.”

We saw evidence that the surgery had recently established a patient participation group. We spoke with two representatives from the group. One said, “It’s not about individuals’ problems it is about how the practice is doing and how it can be run better. I gave a number of points at the meeting and I noticed this morning that it had been done.”