Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Hook Surgery on 8 June 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the comprehensive inspection we found that the practice had failed to do all that was reasonably practicable to ensure that sufficient safeguards were in place when prescribing medicines, this included the bulk prescribing of high-risk medicines such as Warfarin, and the lack of formal guidelines for prescribing by the nurse practitioner; that they did not have processes in place to ensure that the temperature of the vaccines refrigerator was monitored on a daily basis and had failed to keep comprehensive records of action taken when the temperature had gone outside of the optimum range; that they did not do all that as reasonably practicable to ensure that patients who failed to collect prescriptions were followed-up; and that they did not have sufficiently robust processes in place to ensure that there was clinical oversight of all hospital correspondence received.

We also found areas where the practice should make improvements. We found that the practice had been recording significant events, but that their records did not always contain sufficient detail; the practice provided training to its staff but processes in place to identify when refresher training was due had not been maintained; at the time of the initial inspection, the practice's Patient Participation Group had been recently restructured and the new group was in the process of becoming fully established; the practice had identified 13 carers, which represented less than 1% of their patient population.

We undertook this focussed inspection on 9 December 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Hook Surgery on our website at www.cqc.org.uk.

Overall the practice was rated as good following the comprehensive inspection. They were rated as requires improvement for providing safe services. Following the focussed inspection we found the practice to be good for providing safe services.

Our key findings across all the areas we inspected

were as follows:

• There was an effective system in place of reporting and recording significant events.
• The practice’s arrangements for prescribing medicines was in line with guidelines and up to date policies were in place.
• Prescription sheets and pads were stored safely and records were kept of stocks held.
• The practice recorded the temperature of their medicines fridges daily; however, their temperature log did not record full details of action taken when fridge temperatures went out of the optimum range.
• All clinical letters were reviewed by GPs.
• All staff were up to date with mandatory training sessions and processes were in place to flag when training was due.
• The patient participation group continued to meet regularly.
• The practice had identified 13 carers at the time of the initial inspection; however, they felt that this was not a true representation of their carers register and that there had been an error in their data collection. At the time of the follow-up inspection they re-interrogated their patient records system, and we saw evidence that they had 115 carers on their register, which represented 2% of their patient list.

The practice should take action to address the following area:

• They should ensure that full details are recorded of action taken when medicines fridge temperatures go out of the optimum range.

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 Hook Surgery on 8 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events; however, some examples of records that we saw lacked detail about the action taken by the practice.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance; however, their process for reviewing hospital letters did not in all cases enable information to be reviewed by GPs in a timely way.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment; however, there were some staff who had not received refresher training within the guideline period.
• 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.
• Comments from patients about the availability of appointments were mixed, with some saying that they had difficulty getting an appointment when they needed one.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Review prescribing of high risk medicines including Warfarin to ensure that it is in line with guidance for safe prescribing and that safeguards are in place to prevent patients from taking an incorrect dose.
• They must review their monitoring of blank prescription pads to ensure that all those used can be accounted for. They must review their arrangements for checking that patients are collecting their prescriptions.
• They must review their prescribing procedure to include reference to the remit of the independent nurse practitioner.
• They must review their arrangements for processing hospital letters to ensure that all letters are seen by a clinician.
• They must ensure that the temperature of the vaccines refrigerator is recorded on every day that the practice is open, and that a record is kept of the action taken on occasions when the temperature goes outside of the guideline range.

In addition, the provider should make improvements in the following areas:

• They should ensure that their records of significant events include full details of the event and the action taken by the practice.
• They should ensure that all staff attend mandatory training sessions within the guideline timeframes.
• They should review how they involve patients and seek patients opinions of the services provided including developing the Patient Participation Group .
• They should ensure that they are maintaining processes to identify when staff training is due.
• They should review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice