This practice is rated as requires improvement overall. (The previous overall ratings of the practice are, requires improvement on 27 October 2016 and inadequate on 21 November 2017).

There have been three previous inspections of this practice, two of which were comprehensive inspections where ratings were awarded and one, a focused inspection. The focused inspection was carried out to ensure compliance with a warning notice that was served following the 2017 inspection. The focused inspection was not rated.

We initially carried out a comprehensive inspection on 27 October 2016. At this time, the practice was rated as required improvement overall, with safe, effective and well-led rated as requires improvement.

A follow-up comprehensive inspection was undertaken on 8 August 2017 and 5 September 2017. At this inspection the practice was rated as inadequate overall and placed into special measures for a period of six months. The practice was issued with a warning notice.

On 20 March 2018, we then carried out a focused inspection to check that the practice had made the necessary improvements required, as highlighted in the warning notice. We found that they had complied with the warning notice.

We then carried out an announced comprehensive inspection at Nuffield House Doctors Surgery on 21 May 2018. This was to check that the practice had made improvements as identified in our previous inspection and to re-rate all key questions and population groups.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? Requires improvement

At this inspection we found:

• Governance process had improved: partners, clinicians and management staff had lead roles and policies had been updated. There were effective information cascades and staff knew who to go to if they had a concern.
• Patients taking high risk medicines were being reviewed before a repeat prescription was issued.
• Prescribing data was higher than the local and national averages. The practice was aware and had taken steps to improve.
• There was now an up to date infection control policy. Staff had been trained in infection control and regular audits were taking place. There was a COSHH risk assessment.
• There was oversight of training requirements and recruitment checks.
• There were effective systems to manage MHRA and other alerts that may affect patient safety.
• 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.
• There was a weekly ward round at a local care home by the practice’s GP medicine lead.
• There continued to be a low number of carers identified. Carers were directed to the Care Navigator who could provide advice and assistance of a non-clinical nature.
• Systems to share information with other healthcare professionals were regular and effective.
• The practice had implemented a revised policy to recall patients to their health checks; however, data indicated limited improvement in relation to exception reporting.
• Unverified data for 2017/18 indicted that here had been some deterioration in performance in two mental health indicators and one diabetes indicator.
• Clinical audits were being completed and were used to improve performance where identified.
• All staff received an appraisal in the last year. Staff praised the changes that had been made.
• Prescription stationery was stored securely and tracked as it was distributed.
• Learning disabilities checks were being completed.
• Complaints were effectively handled but the record keeping required improvement.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Feedback from the GP patient survey indicated that patients continued to experience difficulty getting through on the phone and accessing appointments. Action had been taken with a view to making improvements.

The areas where the provider must make improvements as they are in breach of regulations 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:

• Continue to take steps to review antibiotic prescribing with a view to making improvements.
• Identify more patients who are carers.
• Improve the documenting of complaints received and action taken, to ensure there is a clear audit trail including replies to complainants and the action taken.

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

We carried out an announced comprehensive inspection at Nuffield House Doctors Surgery over two days, on 8th August 2017 and 5th September 2017. The overall rating for the practice was inadequate. The full comprehensive report on the 2017 inspection can be found by selecting the ‘all reports’ link for Nuffield House Doctors Surgery on our website at www.cqc.org.uk.

Following that inspection, the practice was served with a warning notice in respect of the governance at the practice.

This inspection was an announced focused inspection carried out on 20th March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in 2017. This report covers our findings in relation to those requirements.

We found that the practice had met the requirements of the warning notice.

Our key findings were as follows:

• There were now effective systems to assess and monitor infection control. An audit had been completed which included an action plan. Staff were aware of the infection control principles that were relevant to their role.
• GP locums were now being appropriately engaged. There was evidence that the practice had checked references of conduct in previous employment, identification and training.
• Staff training was now being monitored and recorded.
• All staff were now receiving an appraisal of their performance.
• Staff knew who to go to if they had concerns about infection control or safeguarding children and vulnerable adults.
• The practices had implemented a policy relating to reviewing patients who were prescribed lithium. Evidence confirmed that these patients were being suitably monitored.
• There were 45 patients who were on the learning disability register and aged over 16. 37 of these patients had a health check in the last year.
• Exception reporting relating to a mental health indicator had been reviewed and there were plans to improve performance.

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 Nuffield House Doctors Surgery on 27 October 2016. 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. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, it was not clear if patients always received an apology and explanation, although the provider was aware of the requirements of the duty of candour.
• The system in place for managing patient safety and medicine alerts was not effective.
• The practice had not completed a health and safety risk assessment or an infection control audit.
• Not all staff carrying out the role of chaperone had received a Disclosure and Barring Service (DBS) check and there was no risk assessment in place.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff received appraisals that identified their training needs in order to meet the needs of service users. However we found that the system for monitoring this training required strengthening as some staff had not received training in basic life support and health and safety and other training was out of date.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had identified a low number of patients who were carers.
• Data showed patient outcomes relating to interactions with GPs were low compared to the local and national average.
• The practice was aware of their clinical performance and where improvements were required they had an action plan in place for improvement. However exception reporting was much higher than CCG and national averages in relation to one mental health indicator.
• 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.
• Patients said access to appointments via phone was difficult and the wait was sometimes long.
• The practice had a number of policies and procedures to govern activity, but these were overdue a review.
• The practice had suitable facilities and was well equipped to treat patients and meet their needs.
• Staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

• Ensure staff who act as chaperones either have a current Disclosure and Barring Service (DBS) check or a risk assessment has been completed.
• Implement an effective system for the management of patient safety and medicine alerts.
• Undertake a health and safety risk assessment as required by legislation.

In addition the provider should:

• Improve formal governance arrangements including systems for assessing, monitoring and mitigating risks to patients. Continue to review performance data to improve outcomes for patients.
• Consider ways to further improve patient satisfaction as identified by the national GP patient survey.
• Review and update policies, procedures and guidance.
• Implement a system for ensuring that all staff training is monitored and updated.
• Ensure that patients affected by significant events receive an explanation and a written apology where relevant.
• Ensure that clinical staff are registered with their appropriate bodies and have adequate insurance cover in place.
• Improve the exception reporting rate for patients suffering with poor mental health.
• Ensure that an infection control audit is completed and staff receive immunisations relevant to their role.
• Improve the identification of patients who are carers.

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 Nuffield House Doctors Surgery on 27th October 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 27th October 2016 inspection can be found by selecting the ‘all reports’ link for Nuffield House Doctors Surgery on our website at www.cqc.org.uk.

This inspection was an announced inspection carried out over two days: on 8th August 2017 and 5th September 2017. This was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27th October 2016. This report covers our findings in relation to those requirements and also additional concerns identified at our most recent inspection. We found that sufficient improvement had not been made.

Overall the practice is rated inadequate.

• Governance at the practice was inadequate. There had been significant changes within the partnership over the last year, which had affected leadership. However, there were some improvements made during the course of our inspection.
• The practice’s action plan that was submitted in response to the October 2016 inspection remained outstanding.
• There were systems to review most patients taking high risk medicines although the monitoring of patients taking lithium was not effective. Only one out of six patients taking this medicine had received appropriate monitoring before a repeat prescription was issued.
• The management of patient safety and medicine alerts had improved, as had the system for recording, learning and actioning change as a result of significant events.
• There was a weekly ward round at a local care home by the GP medicine lead at the practice.
• An additional salaried GP had been appointed whose responsibility was to coordinate and manage the care of the practice’s frail patients.
• The infection control audit was incomplete. The infection control policy was dated 2013 and referred to staff who had left the practice. Infection control training was scheduled to take place for all staff members in the weeks following our inspection, as was a further infection control audit.
• The practice had completed a health and safety and fire risk assessment although there was no Control of Substances Hazardous to Health (COSHH) risk assessment.
• Chaperones were now DBS checked which sought to ensure their suitability for the role.
• The practice was now recording immunisation status. They were also recording registration with professional bodies and medical indemnity insurance, although this was not recorded for all members of the clinical team.
• There continued to be a low number of carers identified. Systems to support carers were limited.
• Data showed patient outcomes in respect of interactions with GPs had improved and these were now comparable to the local and national average. However, patient satisfaction was below local and national average in relation to how easy it was for patients to get through on the phone.
• QOF performance continued to be in line with or better than local and national averages. There had been improvements in relation to low performance for one diabetes indicator, although there continued to be high exception rates in relation to a mental health indicator.
• Policies had been updated in respect of safeguarding children and safeguarding adults.
• Non-clinical staff were unclear as to who in the practice was the lead for safeguarding and had not received safeguarding training. Clinical staff had received some safeguarding training, but not to the level required for their role.
• Clinical audits were being completed and were used to improve performance where identified
• There was a lack of systems to ensure the competency of staff. There were gaps across all training. The system to record and review training was inconsistent.
• There were no appraisals completed for non-clinical staff.
• Prescription stationery was stored securely although there were no systems to track its location during the course of the day.
• Recruitment checks were not consistent.
• Evidence of conduct in previous employment and training was not requested when locum GPs were engaged to work at the practice.
• There had been no formal learning disabilities checks in the last year, although a template had been created and a clinical lead for learning disabilities appointed.

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:

• Improve the identification and systems to support patients who are carers.
• Improve patient satisfaction in relation to getting through to the practice by phone.

I am placing this service in special measures. Services 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 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 by adopting our proposal to remove this location or cancel the provider’s registration.

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