Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. However we rated the practice as Requires Improvement for providing well led services. A previous inspection, carried out on 21 April 2015 rated the practice as good overall, with the safe domain rated as requires improvement. A breach of regulation was identified on that occasion. A focused follow up inspection carried out on 4 April 2016 found the practice had carried out the necessary improvements; and the safe domain was rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Lister Lane Surgery on 28 March 2018 as part of our inspection programme.

At this inspection we found:

• The practice had a system for reporting and taking action on significant events. The practice did not retain summary details of significant events, noting actions taken or lessons learned. This meant that learning to help prevent the recurrence of incidents was not always assured.
• The practice had a number of policies and protocols in place in relation to staff activity. However we saw that these were not always appropriately updated, and that updated policies were not always available to all staff, particularly those based at branch sites.
• The process for receiving, disseminating and acting upon Medicines and Health Regulatory Agency (MHRA) and other patient safety alerts was not demonstrable by recorded actions.
• Quality improvement activity, in relation to prescribing, referral and minor surgical procedures was carried out. The practice benchmarked against a number of local practices in relation to accident and emergency attendances and unplanned admissions.
• The practice had systems for dealing with complaints in line with national timescale requirements. We saw that written communication did not contain Parliamentary and Health Service Ombudsman details.
• The practice hosted diabetic retinal eye screening and musculoskeletal (MSK) services. This enabled them to access summary record details pertaining to secondary care for patients.
• Patients were able to access services at any one of three sites operated by the practice. The premises’ facilities were appropriate to meet the needs of patients.
• We observed patients being treated with compassion and respect. Patient feedback we received, both in person and on CQC comment cards provided examples of caring and responsive care being provided by the practice.
• Some patients told us access to the practice by telephone was difficult. The practice told us they were aware of the issue, and had plans in place to improve this.
• At the time of our visit the registration details held by the Care Quality Commission were not up to date. The practice told us they were in the process of addressing these.

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

• 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:

• Establish systems for reviewing the immunisation status of staff, in line with the Department of Health’s guidance.
• Liaise with the landlord with responsibility for their Boothtown branch site to assure themselves that health and safety assessments and processes are completed in a timely manner.
• Review and improve the means by which patients using disabled toilet facilities at the Nursery Lane site are able to alert staff in the event of an accident.
• Comply with infection prevention and control requirements by ensuring sharps bins are appropriately situated, signed and dated at all times, and that all equipment is in date.
• Continue to review and risk assess stocks of emergency medicines and equipment to ensure it is adequate to meet patients’ needs.
• Include the Parliamentary and Health Services Ombudsman details on all written communications in relation to patient complaints.
• Review and improve systems for identifying and supporting patients acting in an unpaid caring role.
• Continue to encourage and educate their patient population to attend appointments with national cancer screening programmes.

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 Lister Lane Surgery on 21 April 2015. The practice was rated as Good overall, however it was rated as Requires Improvement in relation to providing safe services to all the population groups it serves. Breaches of legal requirements were found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe services to the population in serves.

We undertook a desk based review during March 2016. We also visited the practice on 4 April 2016. This was to review in detail the information the practice had sent to us and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those requirements.

The full comprehensive report which followed our inspection in April 2015 can be found by selecting the ‘all reports’ link for Lister Lane Surgery on our website at www.cqc.org.uk

Our key findings across the area we inspected were as follows:

• Risks to patients were assessed and well managed.

• Since our last inspection the practice had carried out fire risk assessments of Lister Lane Surgery and the branch site Nursery Lane Surgery. A third branch surgery Boothtown Surgery operated under the health and safety policies of Caritas Group Partnerships, and was subject to their corporate fire risk assessment. We were shown the detailed fire risk assessments for Lister Lane and Nursery Lane Surgeries, and saw that action plans had been formulated following these assessments and necessary actions had been carried out.
• A legionella assessment had been completed at Lister Lane and Nursery Lane Surgeries.
• An infection prevention and control (IPC) audit had been carried out at all sites operated by the practice. Identified actions had been completed. The practice told us they would complete an annual IPC audit at all sites operated by the practice.
• Medicine storage arrangements had been reviewed and improved to ensure medicines were appropriately logged and stored. We were shown evidence of the practice action plan in relation to medicine storage, and were shown how medicines were safely stored in the practice.

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 Lister Lane on 21 April 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for all the population groups. It required improvement for providing safe services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• 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.
• Staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• Risks to patients were not always assessed and well managed. The practice did not have an infection control audit or fire assessment completed in the last 12 months.
• Not all staff were aware who took the lead for infection control.

The areas where the provider must make improvements are:

• Ensure an infection control audit is completed and action plan implemented in accordance with the findings.
• Ensure a fire assessment of the premises is completed and action plan implemented in accordance with the findings.
• Ensure a risk assessment for legionella testing is completed and action plan implemented in accordance with the findings.

In addition the provider should:

• Review the storage of medicines to ensure they are stored safely and securely and a stock list is kept.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our inspection on the 9 December 2013 found the provider was not carrying out appropriate recruitment checks. Following the inspection the provider wrote to us and told us they would take action to ensure they were compliant with these essential standards.

At this inspection we found that improvements had been made. The provider had reviewed their policies and procedures. The documents provided staff with the actions they must take to ensure only suitable staff were employed at the practice.

As part of our inspection we spoke with three people who used the service and six staff members. This included two doctors, a practice nurse, the practice manager and two reception administration/ health care staff.

The practice had a ‘Patient Reference Group’ (PRG) who met to discuss the services provided by the practice. They told us they expressed their views and were involved in making decisions about the practice. Comments included:

“The practice are brilliant, I am very happy with them.”

“All the reception staff are nice and if you are not well they will fit you in. They really do look after you.”

Staff had received abuse awareness training and procedures were in place to respond appropriately to allegation of abuse.

Appropriate recruitment checks were not in place prior to the employment of staff. This means the practice did not have the necessary checks and risk assessments in place to ensure people were protected from potentially unsuitable staff.

People had their comments and complaints listened to and where appropriate, action had been taken.