Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hetherington Group Practice on 30 March 2016. The overall rating for the practice was good. However, we identified breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which led to the practice being rated as requires improvement for being well led.

Specifically:

• The systems for analysing significant events were not effective in that learning was not clearly documented or communicated to staff.

• Recruitment policies and processes were not effective in that there was no system in place for monitoring the professional registrations of clinical staff.

• The practice did not have a full supply of emergency medicines including rectal diazepam and diclofenac and there was no risk assessment in place to justify the absence of these medicines.

In addition to the breaches of legislation identified we found several areas where we suggested the provider should make improvements:

• Ensure complaints policy and responses comply with requirements of The Local Authority Social Services and NHS Complaints (England) Regulations 2009.

• Ensure that all staff have received required mandatory training including fire safety, information governance and infection control.

• Continue to review and monitor telephone and appointment access.

• Consider drafting a formal strategic business plan.

• Consider undertaking regular internal appraisals for salaried GPs and review the appraisal process for all staff.

• Review patients with mental health concerns and put strategies in place to ensure that their alcohol consumption is discussed and recorded.

• Continue to review patients to ensure that people with Coronary Heart Disease are identified.

• Review the process of internal audit, clearly documenting the action taken to improve outcomes and consider putting this information into a structured written format.

The full comprehensive report from the 30 March 2016 inspection can be found by selecting the ‘all reports’ link for Hetherington Group Practice on our website at www.cqc.org.uk.

This inspection was a desk-based focused review carried out on 13 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 30 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice rating for well led is now good. The practice remains rated good overall.

Our key findings in respect of the breaches of regulation were as follows:

• The practice had a full supply of emergency medicines.

• The practice had an effective system in place for documenting, discussing and learning from significant events.

• The practice had systems in place to monitor the professional registrations of clinical staff.

The practice had also taken action to address the areas where we suggested that improvement should be made:

• The practice detailed information about advocacy organisations patients could contact if they were unhappy with the practice’s response in their complaint acknowledgement letter.

• The practice had systems in place to ensure that staff completed required training in accordance with current legislation and guidance.

• The practice had started drafting a business plan which had involved analysis of practice strengths, weaknesses, opportunities and threats.

• The practice told us that they had held two training sessions with patients to try and increase or improve access to online services thereby easing congestion on the practice’s telephone appointment system. This was in response to a patient survey which indicated that patients were having difficulties using the online appointment system.

• We were provided with an appraisal schedule which indicated that all staff, including salaried GPs, had been appraised after our previous inspection.

• We saw that the practice was taking steps to improve outcomes for mental health patients. Reminders were sent to staff about the importance of undertaking health checks and the practice had planned a clinic for patients suffering from mental illness who resided at a local hostel. In addition the percentage of patients with mental illness who had their alcohol consumption recorded had increased from 63% in the 2014/15 Quality and Outcomes Framework (QOF) year to 72% in 2015/16. However, this was still below the national average of 89% and local performance of 73%. (QOF is a system intended to improve the quality of general practice and reward good practice)

• The practice provided us with evidence to show that the low prevalence of Coronary Heart Disease (CHD) amongst their patient list was in line with local averages. The document provided showed that, while nationally prevalence was 3.4%, the prevalence in south London was 1.97% and in Lambeth this was 1.3% which was similar to the practice prevalence rate of 1.2%. As CHD is generally a disease associated with older people, the lower prevalence was attributed to the practice population which has a higher proportion of younger patients than the national average.The practice informed us that they would continue to make efforts to ensure their CHD prevalence data was accurate by coding patients with this disease on receipt of information from newly registered patients and diagnostic information from secondary care. In addition one of the partners told us that they would undertake regular searches of patients on medicines that were indicative of CHD to ensure coding was accurate.

• The practice provided us with a review of abnormal potassium results. Although the practice identified a potential cause of the abnormal results it was not clear what action the practice had taken in response to their findings and there was no evidence of reviewing this action in order to see if improvements could be made.

Action the practice should take:

• Continue to work to improve the practice’s vision and strategy.

• Continue to work on improving the quality of service provided including work to improve patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

One person, a long standing patient, said, "the reception staff are helpful and polite and the doctors and nurses have treated my family with patience and care." People told us that appointments were long enough to discuss their problems thoroughly. One person said, "they consider my needs properly...I never feel rushed". Another person described the service as "marvellous" and "supportive".

People felt that they had received good advice on a range of medical issues. The surgery website had information to assist people in managing their health care.

All the patients we spoke with were confident in the competency of the doctors and nursing staff. Staff received training in how to respond to situations where a vulnerable adult or child may be at risk. The practice had procedures to deal with such situations and details to make safeguarding referrals were displayed in clinical rooms.

People were cared for by suitably qualified, skilled and experienced staff. People who used the service were asked for their views about care and treatment and they were acted on. There were systems to highlight quality issues and improve services.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. The process to apply for the registration of a new manager is underway.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hetherington Group Practice on 30 March 2016. The overall rating for the practice was good. However, we identified breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which led to the practice being rated as requires improvement for being well led.

Specifically:

• The systems for analysing significant events were not effective in that learning was not clearly documented or communicated to staff.

• Recruitment policies and processes were not effective in that there was no system in place for monitoring the professional registrations of clinical staff.

• The practice did not have a full supply of emergency medicines including rectal diazepam and diclofenac and there was no risk assessment in place to justify the absence of these medicines.

In addition to the breaches of legislation identified we found several areas where we suggested the provider should make improvements:

• Ensure complaints policy and responses comply with requirements of The Local Authority Social Services and NHS Complaints (England) Regulations 2009.

• Ensure that all staff have received required mandatory training including fire safety, information governance and infection control.

• Continue to review and monitor telephone and appointment access.

• Consider drafting a formal strategic business plan.

• Consider undertaking regular internal appraisals for salaried GPs and review the appraisal process for all staff.

• Review patients with mental health concerns and put strategies in place to ensure that their alcohol consumption is discussed and recorded.

• Continue to review patients to ensure that people with Coronary Heart Disease are identified.

• Review the process of internal audit, clearly documenting the action taken to improve outcomes and consider putting this information into a structured written format.

The full comprehensive report from the 30 March 2016 inspection can be found by selecting the ‘all reports’ link for Hetherington Group Practice on our website at www.cqc.org.uk.

This inspection was a desk-based focused review carried out on 13 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 30 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice rating for well led is now good. The practice remains rated good overall.

Our key findings in respect of the breaches of regulation were as follows:

• The practice had a full supply of emergency medicines.

• The practice had an effective system in place for documenting, discussing and learning from significant events.

• The practice had systems in place to monitor the professional registrations of clinical staff.

The practice had also taken action to address the areas where we suggested that improvement should be made:

• The practice detailed information about advocacy organisations patients could contact if they were unhappy with the practice’s response in their complaint acknowledgement letter.

• The practice had systems in place to ensure that staff completed required training in accordance with current legislation and guidance.

• The practice had started drafting a business plan which had involved analysis of practice strengths, weaknesses, opportunities and threats.

• The practice told us that they had held two training sessions with patients to try and increase or improve access to online services thereby easing congestion on the practice’s telephone appointment system. This was in response to a patient survey which indicated that patients were having difficulties using the online appointment system.

• We were provided with an appraisal schedule which indicated that all staff, including salaried GPs, had been appraised after our previous inspection.

• We saw that the practice was taking steps to improve outcomes for mental health patients. Reminders were sent to staff about the importance of undertaking health checks and the practice had planned a clinic for patients suffering from mental illness who resided at a local hostel. In addition the percentage of patients with mental illness who had their alcohol consumption recorded had increased from 63% in the 2014/15 Quality and Outcomes Framework (QOF) year to 72% in 2015/16. However, this was still below the national average of 89% and local performance of 73%. (QOF is a system intended to improve the quality of general practice and reward good practice)

• The practice provided us with evidence to show that the low prevalence of Coronary Heart Disease (CHD) amongst their patient list was in line with local averages. The document provided showed that, while nationally prevalence was 3.4%, the prevalence in south London was 1.97% and in Lambeth this was 1.3% which was similar to the practice prevalence rate of 1.2%. As CHD is generally a disease associated with older people, the lower prevalence was attributed to the practice population which has a higher proportion of younger patients than the national average.The practice informed us that they would continue to make efforts to ensure their CHD prevalence data was accurate by coding patients with this disease on receipt of information from newly registered patients and diagnostic information from secondary care. In addition one of the partners told us that they would undertake regular searches of patients on medicines that were indicative of CHD to ensure coding was accurate.

• The practice provided us with a review of abnormal potassium results. Although the practice identified a potential cause of the abnormal results it was not clear what action the practice had taken in response to their findings and there was no evidence of reviewing this action in order to see if improvements could be made.

Action the practice should take:

• Continue to work to improve the practice’s vision and strategy.

• Continue to work on improving the quality of service provided including work to improve patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice