Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kirkley Mill Surgery on 17 January 2018. The surgery was inspected under the previous provider, East Coast Community Healthcare Community Interest Company (ECCH) on 6 June 2017 and rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services and was placed in special measures. The current provider, Suffolk GP Federation became the provider with the support of the Clinical Commissioning Group on 1 November 2017.

We have inspected, but not rated, some key questions because we did not have sufficient evidence to rate. This was because the service had recently been reconfigured and the historical data related to the previous provider.

The key questions are rated as:

Are services safe? – inadequate.

Are services effective? – not sufficient evidence to rate.

Are services caring? – not sufficient evidence to rate.

Are services responsive? – not sufficient evidence to rate.

Are services well-led? - good.

As part of our inspection process, we also look at the quality of care for specific population groups. We have inspected, but not rated population groups, because we did not have sufficient evidence to rate. This was because the service had recently been reconfigured and the historical data related to the previous provider.

Older People – not sufficient evidence to rate.

People with long-term conditions – not sufficient evidence to rate.

Families, children and young people – not sufficient evidence to rate.

Working age people (including those recently retired and students – not sufficient evidence to rate.

People whose circumstances may make them vulnerable – not sufficient evidence to rate.

People experiencing poor mental health (including people with dementia) - not sufficient evidence to rate.

At this inspection we found:

• Suffolk GP Federation became the provider on 1 November 2017. The management team had developed an action plan based on the identified risks, once they had taken over the management of the practice. The Director of Primary Care and Practice Services Director from Suffolk GP Federation were undertaking the practice management role jointly. Clinical governance was overseen by the Medical Director of Suffolk GP Federation and the practice had appointed a clinical lead GP in January 2018 who was based at the practice.
• Practice staff we spoke with told us that improvements had been made and they felt positive about the future of the practice since Suffolk GP Federation had taken over the management of the practice. They understood that further improvements were required and a plan was in place to continue to address these.
• The practice had an effective system for managing significant events. When they did happen, the practice learned from them, improved their processes and shared the learning with other GP practices.
• An effective process was in place for acting on patient safety and medicine alerts.
• The practice had a plan in place to improve identified safety risks; for example, improved monitoring of patients prescribed high risk medicines, completion of summarising, health and safety risk assessments, infection control and training deemed mandatory by the practice. Not all patients prescribed high risk medicines had been reviewed appropriately before their medicines were re issued. The practice agreed to review the patients identified.
• The practice performance in relation to the Quality and Outcomes Framework (QOF) 2016/2017 was significantly lower when compared to the local Clinical Commissioning Group (CCG) and national averages. The practice was aware of this and shared their performance data for 2017/2018 (unverified) and their plans to continue to improve the coding of patients and their QOF achievement.
• The practice had commenced a programme of quality improvement and had completed eight single cycle audits, although we identified four patients where risks had not been follow up on. The practice agreed to review the patients identified.
• Staff had not all received training deemed mandatory by the practice, for example safeguarding children and vulnerable adults, infection control, basic life support and anaphylaxis and fire safety. The practice had established a training matrix, which included locum GPs and had started to identify where the gaps in staff training were. They were planning face to face training for staff to ensure all staff were up to date. The practice was aware of the need to update the locum information pack.
• Staff involved and treated people with compassion, kindness, dignity and respect. All of the patients and patient representatives we spoke with and received comments from gave positive responses in this area. Information from the July 2017 national GP patient survey showed the practice was below average for its satisfaction scores on consultations with GPs.
• Patients we spoke with found the appointment system easy to use and reported that they were generally able to access care at the right time, although two patients felt continuity of GPs could be improved. The practice was auditing the appointment system.
• Policies and procedures were in place, however staff were not always confident in how to access them and which policies to follow, as some of the policies from the previous provider were still available.
• Staff we spoke with said they felt supported by the new management team, were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.

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

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

The areas where the provider should make improvements are:

• Continue to increase the uptake of annual health checks for patients with a learning disability.
• Formally review the work undertaken by advanced nurse practitioners to obtain assurance of the quality of their work.
• Continue with plans to have Suffolk GP Federation policies and procedures in place and easily accessible for all staff.

This service was placed in special measures in June 2017. Suffolk GP Federation became the provider on 1 November 2017. We have inspected, but not rated, some key questions because we did not have sufficient evidence to rate. The practice will remain 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.

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

This practice is rated as requires improvement overall. (Previous rating published 2 March 2018 – not sufficient evidence to rate.)

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? – Requires improvement

We carried out an announced comprehensive inspection at Kirkley Mill Surgery on 23 August 2018. The surgery was inspected under the previous provider, East Coast Community Healthcare Community Interest Company (ECCH) on 6 June 2017 and rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services and was placed in special measures. The current provider, Suffolk GP Federation became the provider with the support of the Clinical Commissioning Group on 1 November 2017. We undertook an announced comprehensive inspection on 17 January 2018. The practice was rated as inadequate for safe and good for well led. We were unable to rate some key questions because we did not have sufficient evidence. This was because the service had recently been reconfigured and the historical data related to the previous provider. The practice remained in special measures. This inspection was to follow up on breaches of regulation and to provide a rating for the practice.

At this inspection we found:

• Since the Suffolk GP Federation took responsibility for the practice, a number of changes had been made, however work was needed to ensure that systems and processes in place, were fully implemented. Clinical leadership at the practice had improved with a permanent GP clinical based at the practice and a primary care medical director, who also provided clinical leadership.
• Significant improvements had been made in relation to patients prescribed high risk medicines, the management of pathology results and the clinical management of home visit requests.
• Appropriate recruitment arrangements were in place; however, one clinical staff member was still awaiting a Disclosure and Barring Service Check (DBS) and worked unsupervised with patients. The practice was aware of this and following our inspection, evidence of a DBS check for this member of staff was provided.
• The practice had some systems to manage risk so that safety incidents were less likely to happen. Medicines and Health Care Regulatory Authority (MHRA) safety alerts were being logged and acted upon. However, we identified one alert from October 2017, which remained relevant and had not been acted upon. This was before the provider took over responsibility for the practice. The provider agreed to review these patients and include the alert in their review plan. Reception staff were aware of guidance for recognising the deteriorating patient, but specific guidance, for example for sepsis was not in place.
• A range of risk assessments and audits were completed to ensure safety. However, there was no health and safety or premises risk assessment; following our inspection a health and safety risk assessment was undertaken. Not all appropriate emergency medicines were available and no risk assessment had been undertaken.
• Effective systems had been established for the assessment and management of infection prevention and control.
• Improvements were evident for the number of patients whose notes had been summarised and the coding of patients, although work was still needed in these areas to ensure safe and effective care. For example, approximately 1,000 patients’ notes still needed to be summarised.
• We found two Patient Group Directions which had not been authorised. Action was taken immediately to authorise these.
• All staff had received mandatory training appropriate to their role and a management tool had been established to record and monitor this.
• The practice recognised that their Quality and Outcome framework overall achievement for 2017 to 2018 was similar to, and their exception reporting higher than the 2016 to 2017 data that related to the previous provider. Improvements had been recently implemented but the success of these had not been evidenced at the time of our inspection.
• 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 involved and treated patients with compassion, kindness, dignity and respect. All the patients and patient representatives we spoke with and received comments from gave positive responses in this area.
• Patients found the appointment system easy to use and reported that they could access care when they needed it. Continuity of care had improved with the reduction of the number of locum GPs from five (January 2018) to two at the time of the inspection.
• On the day of the inspection, managerial staff at the practice were not able to access the electronic system where significant events and complaints were logged. Staff we spoke with were not all aware of the outcomes of significant events. The systems in place for significant events and complaints were not effectively embedded at a practice level.
• Work had been undertaken to ensure that only Suffolk GP Federation policies and procedures were in place. Staff were confident in how to access and follow them.
• There was a focus on continuous learning and improvement at all levels of the organisation.

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

• 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 areas where the provider 

should

 make improvements are:

• Continue to increase the uptake of annual health checks for patients with a learning disability.
• Improve the system so that all Patient Group Directions are authorised.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.