This practice is rated as Requires Improvement overall. (inspected August 2016 - rated Requires Improvement. Follow up inspection February 2017 - rated Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

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 Pond Tail Surgery on 27 June 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. However, some of these processes were not always implemented effectively, including the processes to monitor and follow up on safeguarding concerns, the recording and oversight of safety alerts, significant events and complaints, and the systems for monitoring patient health in relation to the use of medicines.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice ensured patients had good access to care by offering extended hours surgeries, and telephone consultations, as well as offering appointment booking online.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was an open and transparent approach to safety, significant events and complaints, although we found the recording processes could be improved and learning was not always shared effectively with staff.
• 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.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Strengthen the guidance provided for staff to include identification of symptoms for potentially seriously ill patients, such as sepsis.
• Continue to strengthen the systems used to record learning and share lessons, identified themes and action taken to improve safety in the practice as a result of significant events and complaints.
• Ensure all staff are aware of the practice vision and future planning in relation to their role, and that improvements and innovation within the practice are communicated to all staff.
• Review the arrangements in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
• Continue to monitor and take action where appropriate for areas with high exception reporting on Quality Outcomes Framework.
• Strengthen the programme of clinical audit and quality improvement activity, including to routinely review the effectiveness and appropriateness of the care provided.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pond Tail Surgery on 3 August 2016. During this inspection we found breaches of legal requirement and the provider was rated as requires improvement under the safe and well led domains. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Pond Tail Surgery on our website at www.cqc.org.uk. The practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensuring health and safety systems are robust and the fire risk assessment action plan is fully implemented.
• Implementing a system to monitor hand written and computer printed prescription pads and forms.
• Establishing systems to obtain the views of patients who use their services and other stakeholders and use this in information to develop their services.

Additionally we found that:

• The provider should review their significant event records and complaints to ensure the dissemination of information to all staff is captured.
• The provider should review meetings to ensure staff have appropriate opportunities to share information and good practice.
• The provider should review their current actions regarding legionella testing to ensure this is supported by a risk assessment.
• The provider should review the low QOF outcome result for face to face care plan review meetings for patients with dementia.

This inspection was an announced focused inspection carried out on 9 February 2017 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 3 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• Steps had been taken to address the outstanding actions of the fire safety risk assessment
• A system was now in place to monitor hand written and computer generated prescription pads.
• Steps had been taken to set up systems to take into account the views of patients and other stakeholders.

Additionally:

• The practice was working to meet the needs of patients with dementia. We saw information to demonstrate that the practice was working through the list of patients who required a one to one care plan review. Information we saw confirmed that this was being closely monitored by the practice.
• We saw evidence that significant events meeting minutes were now shared with all staff.

• The practice had engaged an external contractor to undertake a new assessment of their legionella risks.

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 Pond Tail Surgery on 3 August 2016. Overall the practice is rated as requires improvement.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• 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.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were not always assessed and well managed.
• 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.
• 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.
• There was a clear leadership structure and staff felt supported by management.
• The practice did not have formal systems to proactively seek feedback from staff and patients and did not have an active patient representative group.
• The provider was aware of and complied with the requirements of the duty of candour.

• Risks to patients were generally assessed but not always well managed. For example the practice had not responded to the fire risk assessment and a legionella risk assessment had not been undertaken.

The areas where the provider must make improvement are:.

• The provider must ensure health and safety systems are robust and the fire risk assessment action plan is fully implemented.
• The provider must ensure that a system is put in place to monitor hand written and computer printed prescription pads and forms.
• The provider must ensure they establish systems to obtain the views of patients who use their services and other stakeholders and use this information to develop their services.

The areas where the provider should make improvement are:

• The provider should review their significant event records and complaints to ensure the dissemination of information to all staff is captured.
• The provider should review meeting arrangements to ensure staff have appropriate opportunities to share information and good practice.
• The provider should review the current actions regarding legionella testing to ensure this is supported by a risk assessment.
• The provider should review the Quality Outcomes Framework (QOF) exception reporting levels for dementia.
• The provider should review the low QOF outcome result for face to face care plan review meetings for patients with dementia.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This was a follow up inspection that related to infection control.

We found on this follow up inspection that the provider had taken the necessary steps to address areas identified during our previous inspection in November 2013.

We saw that the provider had introduced new systems which ensured that sterilised equipment was checked regularly. We also saw information that related to infection control.

During our visit we spoke with four patients, five members of staff which included two GPs and collected nine patient surveys.

We saw that staff spoke with patients in a respectful way. We noted that staff closed doors of the treatment and consulting rooms that ensured privacy and dignity for patients. All of the patients that we spoke with told us that they felt respected by the staff at the practice. One patient told us they were “Always treated respectfully.”

We saw that the practice had safeguarding policies and procedures that related to adults and children and that staff were aware of these. We noted that there was a lead contact for both child and adult safeguarding at the practice.

We found on the day of the inspection that although the practice seemed clean and hygienic, the provider had not ensured proper systems were in place for the storage of sterile equipment.

We noted that the provider had taken the necessary steps to ensure they employed only suitable staff at the practice.

We saw that the practice had a complaints policy and that this was made available to patients.