We carried out an announced comprehensive inspection at Littleton Surgery on 27 February 2019 as part of our inspection programme.

We had previously inspected the practice in October 2015 where they were placed in special measures. We undertook a further comprehensive inspection in June 2016 where the practice was rated as Good in all domains and population groups.

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.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.
• There was a clear leadership structure and staff felt supported by management.
• Staff worked well together as a team and all felt supported to carry out their roles. There was a strong team ethos and culture of working together for a common aim.
• The practice was using an additional tool to help optimise workflow and which offered clinical decision support through the use of smart templates with clinical pathways, live monitoring of data and advanced reporting.

Whilst we found no breaches of regulations, the provider should:

• Review and continue to monitor cervical smear screening.
• Review and continue to monitor child immunisation rates.
• Ensure the process for prescription monitoring when blank scripts are used in the different rooms is embedded.

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 Littleton Surgery on 2 June 2016. Overall the practice is rated as good. The practice was subject of a previous comprehensive inspection on 14 October 2015. The practice was rated as inadequate for providing well led services, requires improvement for providing safe, effective and caring services and overall and was placed into special measures. We undertook this comprehensive inspection on 2 June 2016 to check that the provider now met the regulations.

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

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Risks to patients were assessed and well managed.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. There were improvements in relation to the GP patient survey results in this area although further improvements were needed in other areas.
• The practice engaged effectively with other services to ensure a good level of continuity of care for patients. Improvements had been made in relation to sharing of information with out of hours services to ensure that the care of vulnerable adults and children was safe.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events, including sharing learning as a result.
• 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 and we saw evidence of clear communication and sharing of learning.
• 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. Patients were highly satisfied with access to appointments within the practice.
• 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 and was in the process of developing their PPG (patient participation group) from a virtual group to face to face.
• Some area of practice performance would benefit from improvements although the practice had an awareness of these and had held discussions on ways to improve such as cervical screening and childhood immunisation rates.
• The provider was aware of and complied with the requirements of the duty of candour.

There were areas of practice where the provider should make improvements;

• Continue to review recall systems in place with a view to improving the uptake of childhood immunisations and cervical cytology.
• Monitor and review results from the GP patient survey with a view to continuing to improve patient’s experience in relation to GP consultations.
• Continue to develop the patient participation group (PPG).

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 FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Littleton Surgery on 14 October 2015. We visited the practice location at Buckland House, Esher Park Avenue, Esher, Surrey, KT10 9NY.

Overall the practice is rated as requires improvement. Specifically, we found the practice to be inadequate for providing well led services. The practice required improvement for providing safe, effective and caring services. The practice was also rated as requires improvement for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). It was good for providing a responsive service.

The practice was subject to a previous comprehensive inspection on 26 November 2014. The practice was rated inadequate for providing well led services, requires improvement for providing safe, effective and responsive services and good for providing caring services. Following the comprehensive inspection on 26 November 2014, the practice sent us an action plan detailing what they would do to meet the regulations. We undertook this comprehensive inspection on 14 October 2015 to check that the provider had followed their action plan and to confirm that they now met the regulations.

Our key findings at this inspection were as follows:

• There was a highly flexible range of appointments to suit most patients’ needs. Patients reported good access to the practice and a named GP or GP of choice, with urgent appointments available the same day.
• The practice engaged effectively with other services to ensure continuity of care for patients. However, information relating to vulnerable adults and children was not routinely shared with Out of Hours services.
• Patient feedback showed that patients did not always feel they were involved in making decisions about their care and did not always have trust or confidence in their GP.
• The practice had improved their recording of significant events, incidents and complaints since our last inspection. However, these were not always reviewed as a team in order to ensure learning and promote continuous improvement.
• There was a lack of effective communication within the management team which meant that information and concerns were not shared and reviewed.
• Risks to staff and patients were not always assessed and managed to ensure they were minimised.
• Care plans for patients identified at high risk of unplanned hospital admission had not been reviewed since our last inspection visit and were not scanned into the practice’s electronic system.
• The practice had not ensured the safe and secure storage and distribution of prescription pads.
• There was a lack of completed clinical audit cycles, review of patient treatment outcomes and use of patient feedback to ensure continuous improvement.
• Appropriate recruitment checks on staff had not been undertaken prior to their employment.
• Staff felt well supported and had received key training appropriate to their roles since our last inspection. Further training needs had been identified and planned. Staff had received regular appraisal of their performance.
• Information about how to make a complaint was available and easy to understand.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure risk assessment and monitoring processes effectively identify, assess and manage risks relating to fire safety and evacuation procedures, the safe storage of archived, paper-based patient records and the management of medical emergencies.
• Ensure clear processes for the review and learning from incidents, significant events and complaints in order to promote continuous improvement and the health, safety and welfare of patients and staff.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure audit cycles are fully completed in order to demonstrate actions taken have enhanced care and resulted in improved outcomes for patients.
• Ensure regular review of patient treatment outcomes to ensure continuous improvement, particularly in relation to childhood immunisations and cervical screening.
• Ensure care plans for patients at risk of unplanned hospital admission are reviewed and updated records are held electronically.
• Ensure information relating to vulnerable adults and children is routinely shared with Out of Hours services.
• Ensure the security and tracking of blank prescription pads at all times.
• Ensure all staff have access to appropriate policies and guidance to carry out their role and which reflect practice processes.
• Ensure the regular review of patient feedback, particularly to improve upon the level of patient dissatisfaction surrounding consultations with GPs.

In addition the provider should:

• Ensure all information available to patients on the practice website and in the practice booklet is up to date.
• Ensure all nurses and GPs complete training in the Mental Capacity Act 2005 as planned.
• Ensure that the practice partnership registration with the Care Quality Commission accurately reflects the partnership status.

I am placing this practice in special measures. Where a practice is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures. Practices 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. The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Littleton Surgery on 26 November 2014. We visited the practice location at Buckland House, Esher Park Avenue, Esher, Surrey, KT10 9NY.

We have rated the practice as requires improvement. Specifically, we found the practice to be inadequate for providing well led services. The practice was good for providing a caring service and requires improvement for providing safe, effective and responsive services. The concerns which led to these ratings apply to everyone using the practice. Therefore the different population groups are also rated as requires improvement. The inspection team spoke with staff and patients and reviewed policies and procedures implemented throughout the practice.

Our key findings were as follows:

• There was a range of appointments to suit most patients’ needs. Patients reported good access to the practice and a named GP or GP of choice, with urgent appointments available the same day.
• The practice engaged effectively with other services to ensure continuity of care for patients.
• Patient feedback showed that patients felt they were involved in making decisions about their care and were mostly treated with kindness and respect. However, one patient we spoke with and five patients who had made complaints, expressed concerns that they were not well supported and had been treated dismissively.
• The practice did not have systems in place to ensure the safety of patients, staff and visitors. Significant events, incidents and complaints were not well recorded and reviewed in order to ensure learning and promote continuous improvement.
• Risks to staff and patients were not assessed and managed to ensure they were minimised.
• Staff were not always well supported in reporting concerns.
• There was a lack of openness and transparency within the management team which meant that information and concerns were not shared and reviewed.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure risk assessment and monitoring processes effectively identify, assess and manage risks relating to the health, safety and welfare of patients and staff.
• Ensure incidents, significant events and accidents are recorded and analysed in order to identify learning points and promote continuous improvement to the health, safety and welfare of patients and staff.
• Ensure audit cycles are fully completed in order to demonstrate actions taken have enhanced care and resulted in improved outcomes for patients.
• Ensure complaints information is accessible to patients within the practice in order to encourage patients to make complaints. Ensure complaints information is shared and reviewed to ensure learning and continuous improvement.
• Ensure criminal record checks are undertaken via the Disclosure and Barring Service for all staff trained to provide chaperone services.
• Ensure all staff receive up to date training in mandatory areas such as safeguarding of vulnerable adults, infection control and where necessary, chaperoning.
• Ensure all staff have access to appropriate policies, procedures and guidance to carry out their role.
• Ensure all members of the management team and staff undergo an annual appraisal of performance.
• Undertake assessment and monitoring of water supplies in order to reduce the risk of exposure of staff and patients to legionella bacteria.

In addition the provider should:

• Ensure processes to record GP responses to blood tests and other results are consistent and generate a clear audit trail.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice