Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 25 February 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to ensuring robust processes were in place for the dispensing and management of medicines.

The provider did not have appropriate arrangements in place for the dispensing of medicines. Medicines were sometimes dispensed by one dispenser to patients without checks by other suitably qualified members of staff. Dispensing staff had not all attained suitable qualifications.

We undertook this focused follow up inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only 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 on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We visited Little St John Street Surgery on the 25 February 2015 and carried out a comprehensive inspection.

The overall rating for this practice is good. We found that the practice provided an effective, caring, responsive and well led service. Improvements were needed to ensure that the dispensary operated in a safe way.

We examined patient care across the following population groups: older people; those with long term medical conditions; mothers, babies, 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 patients in these groups.

Our key findings were as follows:

• The practice was friendly, caring and responsive. It addressed patients’ needs and worked in partnership with other health and social care services to deliver individualised care.

• Patients were satisfied with the appointment system and felt they were treated with dignity, care and respect. They were involved in decisions about their care and treatment and were highly complementary with the clinical care that they received from the practice.

• The needs of the practice population were understood and services were offered to meet these. Feedback from the care homes where patients were registered with the practice was very positive.

• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• There was scope to improve arrangements to ensure patient safety was maintained in relation to the safe management of medicines.

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. Medicines were sometimes dispensed by one dispenser to patients without checks by other suitably qualified members of staff. Dispensing staff had not all attained suitable qualifications.

In addition the provider should:

• Improve the security of the dispensary to reduce the risk of unauthorised access. This includes unauthorised access to prescription pads.

• Have documented records for the checking of the stock of controlled drugs and expired medicines.

• There was scope to further embed learning from significant events, by including dispensing errors and through more effective sharing of learning following investigations.  

• There was scope to improve the process for ensuring that actions had been undertaken following receipt of safety alerts.

• Ensure all staff complete training which is deemed mandatory by the provider to their role and ensure all staff receive an annual appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Little St John Street Surgery on 5 February 2019 as part of our inspection programme. The practice was previously inspected in February 2015 and rated as good overall and requires improvement for providing safe services. On re-inspection in October 2015, the practice was re-rated as good for providing safe services.

Our inspection team was led by a CQC inspector and included a GP specialist advisor and a member of the CQC medicines optimisation team.

Our judgement of the quality of care at this service is based 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 outstanding overall.

This means that:

• People were protected from avoidable harm and abuse and that legal requirements were met.
• We saw improvements in the overall management of the dispensary. However, we found there was no guidance in the standard operating procedure for which medicines should not be included in monitored dosage systems.
• The processes for managing health and safety and infection prevention and control risks were thorough and embedded throughout the practice.
• There were good outcomes for people who used the service and treatment was delivered according to best practice guidance.
• There was a commitment to improving care for patients through clinical audit and research.
• Feedback from people who used the service, those who were close to them and stakeholders was continually positive about the way staff treated people. For example, the practice had achieved higher than the CCG average for every indictor on the GP Patient Survey.
• People who used services and those close to them were active partners in their care. Staff were fully committed to working in partnership with people and making this a reality for each patient.

We saw some examples of outstanding practice:

• The practice visited four of the care homes it supported on a weekly basis. These visits were completed by the same GP for continuity of care. If another GP visited for an urgent visit, they tasked the regular GP to ensure they were updated on patients. The clinicians had spent time carrying out educational sessions for care home staff and encouraged them to report any falls to the practice to complete a falls risk assessment and to have a fully holistic view of the care required by the patient. Referrals to physiotherapists and occupational therapists were made as required. The practice also provided mobile numbers to the staff so they could have immediate access to the practice.
• People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode. There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs, which was accessible and promoted equality. For example, the practice had noted an increase in the number of homeless patients and had adjusted the services to suit their needs. They had set up weekly appointments for a homeless patient at the same time every week to reduce the patients’ anxiety about making appointments.

We rated the practice, and all of the population groups, as outstanding for providing responsive services because:

• Facilities and premises were appropriate and met the needs of a range of people who used the service. For example, the practice had recognised the need to extend their premises and had been successful in doing this, with consultation of external stakeholders and the Patient Participation Group.
• There were several examples of individualised, tailored care that met patients’ needs.
• Patients were able to access the service in a timely manner, in a way that suited them and there was clear continuity of care. Patients reported it was easy to book an appointment with their GP of choice.
• The national GP Patient Survey was above average for outcomes relating to access. All feedback we received on the day was positive about accessing the service.
• Complaints were used as a positive opportunity to drive care forward, to learn from sub-optimal practice and to improve processes.
• The ability to access the service in a timely manner and the choice of appointments, the level of positive feedback and continuity of care affected all population groups.

We rated the practice as outstanding for providing well-led services because:

• Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There were clear, comprehensive plans in place which were aligned with the NHS five year forward view and sustainability was a key focus of away days.
• Staff reported they felt fully engaged with the vision and values.
• A systematic approach was taken to working with other organisations to improve care outcomes.
• The practice had a clear system and process for managing risks within the practice.
• Continuous improvement was a high priority for the practice. Improvement methods and skills were available and used across the organisation, and staff were empowered to lead and deliver change.

We found the provider should:

• Review the standard operating procedure to include medicines which should not be placed into monitored dosage systems.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice