Letter from the Chief Inspector of General Practice

This inspection of Longfield Medical Centre practice carried out on 21 June 2017 was to check improvements had been made since our last inspection on 18 February 2016. Following our February 2016 inspection the practice was rated as requires improvement overall. Specifically they were rated as requires improvement for safe and well-led, and good for caring, effective and responsive. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Longfield Medical Centre on our website at www.cqc.org.uk.

As a result of our findings at the inspection in February 2016 we took regulatory action against the provider and issued them with requirement notices for improvement.

Following the inspection on 18 February 2016 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the breaches of regulations.

At this inspection we found that the majority of the improvements had been made and progress had been made across all areas of concern. Overall the practice is now rated as good.

Our key findings were as follows:

• Significant events were fully investigated, patients received support, honest explanations and apologies. The learning was shared with appropriate staff.
• There was a clear recruitment process in place for permanent and locum staff, including an induction process.
• There were disclosure and barring service checks in place for all staff.
• Staff performing chaperone duties had received appropriate training for this role.
• There were systems in place to ensure safe medicines management both within the practice and the dispensary.
• There was a system in place to deal with any medicines alerts.
• Prescription paper was monitored and stored securely.
• Infection control audits were completed and action taken to resolve any issues.
• Policies and procedures were up to date and staff were aware of where to find them and their contents.
• A range of audits and re audits had been completed to improve the quality of service provision.
• Clinical outcomes for patients with diabetes were lower than Clinical Commissioning Group (CCG) and national averages for patients for the year 2015 to 2016 however we saw data from 2016 to 2017 which demonstrated improved outcomes for those patients.
• The practice had a clear system for identifying and supporting the carers on their register, although the numbers of carers identified were low.
• The complaints policy was clearly visible to patients. Complaints were fully investigated and there was a clear audit trail of actions taken by the practice.
• There was a process in place to gather and act on patient feedback.
• Staff had worked as a team and felt confident anything they raised as either an issue or suggestion for improvement would be followed up.
• Changes to senior nursing hours meant the team lacked direct leadership and cohesion.

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

The provider should:

• Review patient group directives (PGDs) to make sure that nursing staff are only using ones that contain the correct authorisations.
• Check that cleaning is being completed as per cleaning schedules.
• Check that small equipment used, such as, airways forceps, are either single use and packaged in sterile containers or appropriately sterilised.
• Review the nursing structure to provide more leadership.
• Review staff understanding of the components of the Mental Capacity Act.
• Improve the identification of patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection on 29 October 2013, we found the service to be welcoming with friendly staff. We saw that on arrival at the service people could speak to reception staff or use the touch in booking screen. People told us staff treated them respectfully and were helpful. One person told us: “I think it’s a very good surgery, very friendly.”

People told us that their treatment was clearly explained to them and they were able to ask questions and make choices about their treatment or medication. This enabled people to make informed decisions regarding their care.

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms. Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided.

There were effective systems in place for the safe prescribing and dispensing of medication.

We saw that staff had received regular training and appraisals. The service had systems in place to monitor the quality of the service provided to people.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Longfield Medical Centre on 18 February 2016. Overall the practice is rated as requires improvement.

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. However, reviews and investigations were not always thorough enough. Themes and trends were not identified and actions were not monitored.

• The practice was unable to demonstrate they carried out infection control risk assessments. The practice was not routinely carrying out infection control audits and there had only been one in the last three years.

• Risks to patients were generally assessed and well managed, with the exception of those relating to Disclosure and Barring Service (DBS) recruitment checks.

• Expired controlled drugs were not being disposed of in a timely way.

• Blank prescriptions were not securely locked away, logged or monitored.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Some staff had not received regular appraisals.
• Some staff undertaking chaperone duties were not formally trained.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice did not have an effective system to identify carers or to offer them support.
• Information about services and how to complain was available and easy to understand. However verbal complaints were not being recorded.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The appointment system was often difficult to access, including appointments not being available unless they were made at particular times of the day (for example, immediately after the practice opened). The practice had initiated improvements.
• There was a clear leadership structure but staff told us that the practice worked in silos and they were not always provided with information to enable them to carry out their roles effectively. Some staff told us there was on occasions an atmosphere of intimidation and bullying and that when they tried to raise concerns they were not treated with respect, listened to or their suggestions acted on.
• Some practice policies and procedures were not being kept up to date.
• The practice did not hold regular governance and team meetings and issues were discussed on an ad hoc basis. Minutes were not being recorded.
• The provider was aware of and complied with the requirements of the Duty of Candour, when providing patients with explanations if things went wrong.

The areas where the provider must make improvement are:

• Disclosure and Barring Service (DBS) checks must be undertaken for all staff providing clinical care to patients or complete a risk assessment explaining why a DBS check is not required.

• Ensure that staff carrying out chaperone duties have received appropriate training.

The areas where the provider should make improvement are:

• Consider advertising the availability of chaperone services in the waiting area in addition to the consulting rooms.

• Carry out an infection control audit.

• Ensure that blank prescriptions are logged and their issue monitored.

• Implement an effective system to identify carers and provide them with appropriate support.

• Ensure non clinical safety incidents identified are investigated and themes and trends are identified to mitigate re-occurrence. Ensure that an audit trail is available to demonstrate that improvements have been actioned and that all relevant staff receive the feedback from any such analysis.

• Provide, supportive relationships among staff so that they feel respected, valued and supported.

• Review and update practice, policies, procedures and guidance.

• Ensure verbal complaints are recorded and acted on.

• Ensure the recent changes made to improve the appointment system are reviewed to improve patient satisfaction.

• Ensure there is an effective system to identify patients who were carers and to offer them support.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice