We carried out an announced comprehensive inspection at Litcham Health Centre on 29 November 2018 as part of our inspection programme.

The practice was previously inspected in November 2016 and rated as outstanding overall with the safe domain rated good.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Feedback from patients was consistently positive and was higher than local and national averages.
• Quality outcomes were consistently higher than the Clinical Commissioning Group and England averages.
• Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care, particularly for older people and people with long term conditions.
• The practice ran an admissions avoidance team employed by the practice to ensure that housebound patients and patients unable to attend the surgery could be appropriately assessed and have support in the community. The team used both the clinical system and ‘priority boards’ in their office to keep up to date with changes in the care provided to patients on different registers. This led to a reduction in accident and emergency admissions and inappropriate hospital referrals. Data showed that the practice was second lowest for A&E attendance and hospital admission in the CCG.
• There was a system for following up patients who failed to attend for administration of long-term medication. There was use of a Patient Passport tool, an encrypted smartcard that allowed healthcare information to be seen by authorised personnel. The Patient Passport alerted staff if there were any outstanding tests due or additional clinical input required. The Patient Passports were directly linked with local hospital data and allowed the extended healthcare team to access the patient's key medical information outside of the practice.

We rated the practice as requires improvement for providing safe services because:

• The practice did not have effective systems and processes to keep patients safe.
• The practice did not have appropriate systems in place for the safe management of medicines.
• The practice did not have effective infection prevention and control systems and processes in place.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Continue to review antibiotic prescribing to ensure it is appropriate.
• Provide guidance for non-clinical staff for identifying deteriorating or acutely unwell patient’s suffering from potential illnesses such a sepsis.
• Risk assess the remote collection points service for medicines dispensed by the practice.
• Review the implementation of standard operating procedures in the dispensary.
• Implement the schedule for staff appraisals.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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 Litcham Health Centre on 9 November 2016. We had previously inspected Litcham Health Centre on 21 January 2015 and rated the practice as requires improvement. The practice has now been rated as outstanding. 

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.
• Risks to patients were assessed and well managed.
• We received 187 patient comment cards, which represented feedback from 5% of the patient list. Comments were consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• Data from the National GP Patient Survey published in July 2016 showed that patients rated the practice higher than others for most areas of care. For example, 97% of patients surveyed said that the last GP they saw or spoke to was good at treating them with care and concern, in comparison to the local average of 89% and the national average of 85%.
• 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.
• Patients said they found it easy to make an appointment with a GP and that there was continuity of care. Urgent appointments were available on the same day.
• 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 well 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.

We saw several areas of outstanding practice:

• A specialist community support team had been directly employed by the practice to ensure that housebound patients and patients unable to attend the surgery could be appropriately assessed and have support in the community. The community support team used both the clinical system and ‘priority boards’ in their office to keep up to date with changes in the care provided to patients on different registers. This had led to a reduction in accident and emergency admissions and inappropriate hospital referrals. Data showed that the practice’s rate of emergency admissions was one of the lowest in the region.
• There was an overarching use of a risk stratification tool to monitor patient health outcomes. The lead GP at the practice had lead on the implementation of this tool within the CCG and provided ongoing support with information technology. Benchmarking data showed that the practice were high achievers in all clinical areas in listed within the system. For example, the practice was ranked third out of 1152 participating practices for the overall monitoring of the eight key care processes for patients with diabetes. Furthermore, the practice hospital admission referral rates were significantly lower than all other local practices.
• Data held on the risk stratification tool was linked with a Patient Passport tool, an encrypted smartcard that allowed healthcare information to be seen by authorised personnel. The Patient Passport alerted staff if there were any outstanding tests due or additional clinical input required. The Patient Passports were directly linked with local hospital data and allowed the extended healthcare team to access the patient's key medical information outside of the practice. We received positive patient feedback about the tool.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We visited Litcham Health Centre on the 9 February 2015 and carried out a comprehensive inspection. The provider had previously been inspected on 14 and 17 January 2014 and on the 8 July 2014 and we were also following up to see if improvements had been made.

The overall rating for this practice is requires improvement. We found that the practice provided a caring and responsive service. Improvements were needed to ensure that the practice was safe, effective and well led.

We examined patient care across the following population groups: older people; those with long term

medical conditions; families, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health. We found that care was tailored appropriately to the individual circumstances and needs of the majority of the patients in these groups.

Our key findings were as follows:

• The practice was friendly, caring and responsive. Patients were empowered to be involved in their care and treatment and were satisfied with the care that they received from the practice.
• Patients were satisfied with the appointment system and felt they were treated with dignity, care and respect.

• The needs of the practice population were understood and services were offered to meet these. The practice had undertaken work to ensure that the health needs of those patients who did not regularly attend the practice were identified and met.
• The practice had started to introduce patient passports. These provided patients with access to their medical information which could be shared with other organisations if the patient chose to.
• The practice employed a registered mental health nurse who provided support to patients in their own homes and undertook dementia screening and health reviews.

However, there were also areas of practice where the provider needs to make improvements.

The provider must:

• Improve arrangements for the safe management of medicines. The provider did not have appropriate arrangements in place for the dispensing of medicines as prescriptions were not always signed by a GP before they were dispensed and handed to patients.
• Ensure that the risks to patients, staff and visitors are assessed. This includes undertaking a health and safety and fire risk assessment and a risk assessment of the dispensed medicines collection service.
• Improve infection control prevention measures. Issues were identified in January 2014 and had not been completed.
• Ensure that staff are supported and mandatory training appropriate to staff roles and appraisals are completed for all staff, including dispensing staff.

In addition the provider should:

• Review the recruitment policy to ensure appropriate recruitment checks are undertaken prior to employment.

• Ensure that policies and procedures are up to date and reviewed regularly.
• There was scope to improve both the process for reporting significant events, so that it included dispensing errors and was timely, and to improve documentation of the investigation and the learning from significant events.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We visited Litcham Health Centre to check that two of the five compliance actions set following our inspection on 14 January 2014, had been completed. We met with the practice manager (who had only been in post for a few weeks) and spoke with five other members of staff including the lead dispenser and the GP with lead responsibility for safeguarding. We did not speak with patients on this occasion but did include their comments as part of the original inspection.

We found the provider had taken action to ensure the safety and disposal of controlled drugs. Improvements had also been taken to the safe keeping of refrigerated medicines and medication used by the practice nurses during their clinics.

While some improvements had been made to improve staff knowledge and awareness of safeguarding issues, staff had not all received the training they needed to enable them to identify the possibility of abuse so that steps could be taken to help protect vulnerable patients and prevent abuse from happening. Staff had been able to demonstrate this was work in progress and further actions were planned.

We spoke with eight patients who were very complimentary about the service they received and told us they were looked after very well by staff. One person said, “This place is wonderful and could not be any better, they do a really good job here.”

Evidence we reviewed demonstrated that clinical care and treatment was tailored to meet individual needs.

Although allegations of abuse had been responded to, other steps to identify and prevent possible abuse had not been taken such as staff training and relevant procedures.

Appropriate arrangements were in place in relation to obtaining, recording, handling and disposing of medicine. However staff did not dispose of controlled drugs in a timely way. Medicines were prescribed and given to people appropriately but not all medicines were kept safely.

The premises were not suitably designed for people with a disability. Some maintenance issues had been neglected and this placed patients, staff and visitors at risk of unsafe or unsuitable premises.

Evidence demonstrated that people were cared for, or supported by, suitably skilled and experienced staff. However recruitment and selection processes were not in place to ensure that appropriate checks were undertaken before staff began work.

People’s personal records including medical records were accurate and fit for purpose. However staff records and other records relevant to the management of the service were not always accurate and fit for purpose.