Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at LPS – The Surgery on 25 January 2017. This inspection was in response to previous comprehensive inspections at the practice in February 2015 and May 2016, where breaches of the Health and Social Care Act 2008 were identified. You can read the report from our last comprehensive inspection on 25 January 2017; by selecting the 'all reports' link for LPS – The Surgery on our website at www.cqc.org.uk.

This inspection on 25 January 2017 was undertaken to follow up progress made by the practice. Overall we found significant improvements had been made, but the practice continued to be an outlier for the Quality and Outcomes Framework (QOF) and other national clinical targets. However we saw evidence that the practice was working to address this and that some improvements had been made on previous QOF achievements. QOF is a system intended to improve the quality of general practice and reward good practice. The practice is now rated as Good overall.

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.
• Patients we spoke with on the day of the inspection were positive about the staff. We saw that staff were friendly and helpful and treated patients with kindness and respect.
• The practice had introduced a programme of audits that were driving improvements in patient outcomes.
• The practice had introduced a system to identify patients that were no longer living within the local area and who could be removed from the practice list in order to address the low uptake of clinical and national targets.
• There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• There were information leaflets available in various languages including Urdu and Romanian. The practice had a large number of Romanian patients on the practice list. To support this group of patients, the practice had interpreters available to aid patients during consultations.

• The provider was aware of and complied with the requirements of the duty of candour.
• There was a clear leadership structure and staff felt they were supported by the practice manager and GPs. The practice had set up a virtual patient participation group (PPG), which was in its infancy; there was evidence that the group was committed to working with the practice to improve the service.

The areas where the provider must make improvements are:

• Assess and monitor performance against national screening programmes and clinical targets to improve outcomes for patients.

The areas where the provider should make improvements are:

• Continue to develop the patient participation group and encourage more patients to join
• Review the current system of monitoring emergency medicines to ensure the recommended medicines are available at all times.

I confirm that this practice has improved sufficiently to be rated Good overall. 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 an announced comprehensive inspection at LPS – The Surgery on 9 May 2016. Overall the practice is rated as requires improvement. This inspection was in response to our previous comprehensive inspection at the practice on 9 February 2015 where a breach of the Health and Social Care Act 2008 was identified with the practice rated as inadequate overall and placed into special measures. Following that inspection we issued a requirement notice to inform the practice where improvements were needed. The practice subsequently submitted an action plan to CQC on the measures they would take in response to our findings.

The identified breach found at the previous comprehensive inspection on 9 February 2015 related to insufficient governance arrangements being in place at the practice to regularly assess and monitor the quality of the services being provided.

At our inspection on 9 May 2016 we found that the practice had improved and was now meeting the requirements of the breach identified at the previous inspection. However, the practice had not sufficiently improved for the effective domain with a breach found under Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. This meant that the practice was still rated as inadequate for the effective domain and requires improvement overall.

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

• Significant events had been logged using a reporting form and we saw evidence to indicate that significant events were discussed at meetings.
• Risks to patients were assessed and well managed.
• National patient survey results were mixed. For example, patient satisfaction rates related to access and interactions with reception staff were rated above CCG and national averages whilst GP consultations were rated lower. However, results were slightly better in a more recent survey conducted by the practice using an external company.
• The practice was found to be an outlier for QOF (or other national) clinical targets in diabetes, mental health, hypertension and cervical screening.We saw evidence that practice were working to address this and that some improvements had been made on previous QOF achievement. However, the practice remained below CCG and national averages.
• Information about services and how to complain was available with a complaints poster displayed in the waiting area and complaints information also found in the practice leaflet and website. We saw that verbal complaints were also being logged to pick up all trends and themes.
• We saw that there were some information leaflets available in the Romanian and Urdu languages as there were a large number of these patients on the practice list. The practice also held ‘Romanian Clinics’ with interpreters three times a week.
• Patients 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.
• The practice had carried out clinical audits to improve patient outcomes.
• There was a clear leadership structure and staff felt supported by management. The practice had sought feedback from staff and patients although the practice had difficulty with engaging with their transient patient list population.

The areas where the provider must make improvements are:

• Make further improvements in the management and monitoring of outcomes for patients.

In addition the provider should:

• Consider the ways in which patients with hearing difficulties may be appropriately supported at the practice.
• Continue with efforts to engage with and seek feedback from patients and record action taken as a result of their feedback.
• Progress steps taken to develop multidisciplinary working for patients on the palliative care register.
• Further develop and strengthen the business development plan to ensure continuity of the service over the next three to five years.

I confirm that this practice has improved sufficiently to be rated Requires Improvement overall. However, the practice has been rated as inadequate for the effective domain and as a result remains in special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 varying the terms of their registration within six months if they do not improve.

The service 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.

Special measures will give people who use the service 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 an announced comprehensive inspection at LPS – the Surgery on 9 February 2015. During the inspection we gathered information from a variety of sources. We spoke with patients, interviewed staff at all levels and checked that the right systems and processes were in place.

Overall the practice is rated as inadequate. Specifically, we found the practice to be inadequate in providing effective and well led services and requires improvement for providing safe services. We found the practice was good for providing a caring and responsive service. They were also inadequate for providing services for the six population groups:

• Older people
• People with long term conditions
• Families, children and young people
• Working age people (including those recently retired and students)
• People whose circumstances make them vulnerable
• People experiencing poor mental health (including people with dementia)

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

• The practice team understood the needs of their local population.
• Staff at the practice were aware of the need to report incidents, complaints and safeguarding concerns however there was no evidence that these were used to improve the quality of the service provided and that learning was shared with staff.
• Systems were in place to protect vulnerable children and adults from the risk of abuse.
• There was no evidence of completed audit cycles to drive improvements in performance and patient outcomes.
• Not all staff had received annual appraisals with identified learning and development needs.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients told us they were generally satisfied with the appointments system and urgent appointments were usually available on the day they were requested.
• The practice did not hold regular governance meetings and issues were discussed at irregular, informal meetings.

The areas where the provider must make improvements are:

• Develop the effective operation of system to analyse significant events and incidents and ensure learning is recorded, identified and shared with staff and contributes to improvements in service delivery.
• Ensure audits of practice are undertaken, including completed clinical audit cycles to monitor performance and demonstrate improved outcomes for patients.
• Ensure there are formal governance arrangements in place to regularly assess and monitor the quality of the services provided.

In addition the provider should:

• Ensure that all multiagency involvement with patients is recorded on the patient record in the practice’s computer system and shared with the practice, particularly safeguarding referrals.
• Develop a robust process to ensure that all test results are prioritised as they are received to prevent any possible delay to the treatment required for the patient
• Ensure that all multidisciplinary meetings with other health professionals are recorded to evidence the benefits of joined up working and positive outcomes for patients
• Develop the existing risk log to include the mitigating actions that need to take place to reduce and manage the risks.
• Continue to seek feedback from staff and patients and record action taken as a result of their feedback.
• Develop a business strategy to strengthen and ensure continuity of the service over the next three to five years and share with staff
• Ensure that all staff have an regular appraisal and personal development plan including the practice manager.

On the basis of the ratings given to this practice at this inspection I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our last inspection in October 2013, the surgery did not have appropriate arrangements in place for dealing with medical emergencies. The provider did not have an effective system in place for monitoring the quality of service provision. We saw that the system in place to ensure patient’s paper records were accurate and fit for purpose was not robust. We set compliance actions and told the provider to improve.

The purpose of this inspection was to see if improvements had been made since our last inspection in October 2013. We gave the provider short notice of our inspection so that any disruption to patient's care and treatment were minimised. During the inspection we spoke with five members of staff, this included the practice manager and the lead GP who was also a partner at the practice. We also spoke with five patients. We found that the provider had made the necessary improvements.

There were arrangements in place to deal with foreseeable medical emergencies.

The provider had improved the system in place for monitoring the quality of service provision. One patient told us, "The care that I get is excellent I have no complaints". Another patient told us, "I have no complaints as I am happy with the service".

Patient’s paper records were accurate and fit for purpose.

This practice is rated as Good overall. (Previous inspection January 2017 – Good overall, with requires improvement rating for providing Effective services)

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? – Good

We carried out an announced comprehensive inspection at LPS The Surgery, also known as Cotterills Lane Surgery on 24 April 2018. This inspection was in response to previous comprehensive inspection at the practice in January 2017, where breaches of the Health and Social Care Act 2008 were identified. You can read the report from our last comprehensive inspection on 25 January 2017; by selecting the 'all reports' link for LPS – The Surgery on our website at www.cqc.org.uk.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• In order to manage recalls and screening with a transient population, the practice continued to monitor patients that were registered at the practice, to ensure patients that were no longer living within the local area were removed from the practice list..
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had achieved higher than average results for several aspects of care from the 2017 National GP Patient survey.
• The practice had a large number of Romanian patients on the practice list. To support this group of patients, the practice had organised interpreters four afternoons a week to aid patients during consultations.
• The practice had tried to set up a virtual patient participation group (PPG), however this had been unsuccessful. The practice continued to try and encourage patients to join the patient participation group and we saw evidence to support this.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients commented positively on the care received by the practice.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to encourage patients to attend screening programmes.
• Review and improve the process to increase interest in patient participation group.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice