This practice is rated as requires improvement overall. (Previous rating October 2017 – Requires Improvement and August 2015 – 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 requires improvement overall.

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

• The security of prescription pads was ineffective.
• The practice did not have an effective system for the recording of significant events and learning from these to make improvements was not clearly demonstrated.
• Areas identified as in need of action from the infection control audit were not followed up.
• Fridge temperatures were not clearly monitored, and the practice had no cold chain policy in place.
• Locum GP checks including immunity status and training checks were not carried out.
• There were no risk assessments in place for the security of the premises and also for the storage of hazardous substances.

We rated the practice as requires improvement for effective because:

• The practices clinical outcomes indicators for 2017/2018 for people experiencing poor mental health and for people with long term conditions, in particular those with diabetes was below local and national averages. Although the unverified data from 2018 shows an increase we found no action plan to indicate these figures had been fully addressed.

We rated the practice as requires improvement for well-led because:

• While the practice had made some improvements since our inspection in October 2017 it had not completely addressed the requirement notice in relation to the infection control audit. At this inspection we also identified additional concerns that put patients at risk.
• The practice lacked a system for quality assurance including clinical audit.
• We also found there was a lack of governance and performance was not being monitored effectively

We rated the population group people experiencing poor mental health as requires improvement because:

• The practice’s clinical outcome indicators for 2017/2018 were below the local and national average for people experiencing poor mental health. The unverified data from this year showed an increase however it remained lower then local and national averages. As this population group was rated as requires improvement for providing effective services, this means that the overall rating for this population group is requires improvement.

We rated the population group people long term conditions as requires improvement because:

• The practice’s clinical outcome indicators for 2017/2018 were below the local and national average for people with long term conditions, in particular for diabetes. The unverified data from this year showed an increase however we found no action plan to indicate these figures had been fully addressed. As this population group was rated as requires improvement for providing effective services, this means that the overall rating for this population group is requires improvement.

We rated the practice as good for providing caring & responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patient’s needs. Patients could access care and treatment in a timely way.
• Patients received effective care and treatment that met their needs.

During our inspection in October 2017 we identified some breaches of the regulations and issued the practice with a requirement notice for improvement. The areas where the provider must make improvements were:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example,
• Implement a system to evidence the action taken in response to national safety alerts
• Implement an effective system to identify staff learning needs including the completion of essential training and regular staff appraisals.
• Undertake infection prevention and control audits.
• Ensure documentary evidence of appropriate recruitment checks for staff members.

At this inspection we found that some areas had been satisfactory addressed however there were still some areas that remain unresolved and therefore the requires improvement rating remains.

During our inspection in October 2017 we also identified other areas where they should improve. The areas where the provider should make improvements were:

• Continue to improve patient satisfaction data in relation to patient waiting times.
• Ensure an appropriate system is in place for the safe use of prescription pads and the management of uncollected prescriptions.
• Implement a system to ensure patient care plans are reviewed and monitored on a regular basis.
• Implement systems to identify and support carers.
• Review practice policies on a periodic basis.
• Maintain a copy of the business continuity plan off the premises.
• Record and analyse verbal complaints and manage all complaints in accordance with the practice policy and the recognised guidance and contractual obligations for GP’s in England.
• Undertake a review of significant events and complaints over time to identify trends.
• Most of these areas had been addressed and improvements put in place however we identified that the security of blank prescription pads needed strengthening which the practice was made aware of on the day of the inspection and also that the documentation of significant events needed reviewing and learning from the significant events did not always identify how it drove improvements.

During our inspection in December 2018 we identified actions which the provider had not fully addressed.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

• Ensure that adequate locum checks are carried out including reassurance of their current immunity status and that safeguarding training is up to date.
• Continue to improve QOF data in relation to those patients with long term conditions.
• Carry out risk assessments in relation to the security of the premises and for the storage of hazardous substances to ensure there is a safe environment for patients and staff.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Melbourne House on 26 August 2015. Overall the practice is rated as good.

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

• There were procedures in place for reporting and investigating significant safety events. However these were not followed consistently and we found safety incidents which had not been investigated.
• Risks to patients were not consistently assessed and well managed. There were systems for assessing risks including risks associated with medicines, premises, and equipment. The practice did not have a business continuity plan for dealing with untoward events which may affect the day to day running of services.
• Staff were not recruited consistently. Checks such as employment references and Disclosure and Barring Services (DBS) checks had not been carried out for all staff.
• Staff who undertook chaperone duties were not trained and did not have DBS checks.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Clinical audits and reviews were carried out to make improvements to patient care and treatment.
• Staff had received training appropriate to their roles. However training updates and refresher training had not taken place and staff had not received an appraisal within the previous 12 months.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Complaints were investigated and responded to appropriately and apologies given to patients when things went wrong or their experienced poor care or services.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. Some patients said that they sometimes had to wait past their appointment time to see their GP.
• 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.

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

Importantly the provider MUST:

• Ensure that risks to patients are assessed and managed. This includes ensuring that safety incidents and near misses are managed consistently with a full investigation and acted upon to minimise recurrences.

• Ensure that staff are employed with all of the appropriate checks including employment references and Disclosure and Barring Services (DBS) checks carried out.

Additionally the provider SHOULD:

• Carry out regular infection control audits to test the effectiveness of the infection prevention and control systems within the practice.

• Ensure that staff training updates are completed.

• Ensure that staff have annual appraisal.

• Develop a business continuity plan for dealing with any untoward incident whish may impact on the day to day running of the practice.

• Review and amend policies and procedures so that they reflect current practices and relevant guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We found Melbourne House Surgery staff to be courteous and welcoming to people during our inspection on 13 August 2013. There was a selection of information in the waiting room for the benefit of the patients. This information included notices about the services available, health promotion, and other support services.

We received positive comments from six people during the inspection. One person told us: "I’m happy with the surgery I’ve never had a problem getting an appointment. Sometimes it’s difficult to get through on the phone, but it’s nice here they’re all friendly and helpful."

We saw that staff spoke politely to people and the consultations were carried out in separate private treatment rooms.

The doctors we spoke with told us they involved people in their care. One doctor told us: "We are a family practice and know our patients well; we involve our patient participation group in service discussions and ask for their feedback.”

The provider protected people against the risks associated with medicines because they had appropriate arrangements in place to manage medicine.

We spoke to four members of staff about the support they received, and saw records of appraisals, training, and development.

We saw that the provider had a records storage system and people's records were stored appropriately and securely.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Melbourne House Surgery on 19 October 2017. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety in most areas. However, there was no clear system in place to evidence what actions had been taken in response to national safety alerts.
• 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. However, the system and process to identify staff learning needs and ensure staff received essential training was not effective.
• Results from the National GP Patient Survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. However, the practice did not always provide essential information when responding to complaints
• Patients we spoke with 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.
• 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. However, not all governance structures, systems and processes were effective and enabled the provider to identify, assess and mitigate risks to patients, staff and others.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We carried out a comprehensive inspection at Melbourne House Surgery in August 2015. During our inspection in October 2017 we identified actions which the provider had not fully addressed. The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example,
• Implement a system to evidence the action taken in response to national safety alerts.
• Implement an effective system to identify staff learning needs including the completion of essential training and regular staff appraisals.
• Undertake infection prevention and control audits.
• Ensure documentary evidence of appropriate recruitment checks for staff members.

We carried out a comprehensive inspection at Melbourne House Surgery in August 2015. During our inspection in October 2017 we identified actions which the provider had not fully addressed. The areas where the provider should make improvements are:

• Continue to improve patient satisfaction data in relation to patient waiting times.
• Ensure an appropriate system is in place for the safe use of prescription pads and the management of uncollected prescriptions.
• Implement a system to ensure patient care plans are reviewed and monitored on a regular basis.
• Implement systems to identify and support carers.
• Review practice policies on a periodic basis. Maintain a copy of the business continuity plan off the premises.
• Record and analyse verbal complaints. Manage all complaints in accordance with the practice policy and the recognised guidance and contractual obligations for GPs in England.
• Undertake a review of significant events and complaints over time to identify trends.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice