This practice is rated as Good overall.

(A previous inspection undertaken on 9 November 2017 had rated the practice as requires improvement overall.)

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 Primrose Surgery on 9 November 2017. The overall rating for the practice at that time was requires improvement. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Primrose Surgery on our website at

www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 23 August 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulations, that we identified in our previous inspection on 9 November 2017. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

At this inspection we found:

• The practice had addressed all issues and areas of concern, which had been identified at the previous inspection.
• There was evidence of good management and clinical leadership, which was supported by organised systems and processes.
• There were noteworthy improvements in the reporting, recording and discussion of significant events. We saw evidence of learning from events and that action was taken to prevent the same thing happening again.
• There was a clear process for dealing with complaints. All complaints to the practice were recorded and reviewed with the staff team.
• There was regular staff engagement, through the use of appraisals and mentorship. The practice had introduced task lists for non-clinical staff which enabled leaders to undertake a weekly review of progress and target support for staff when needed.
• There was evidence of good patient engagement, through the use of the patient participation group, a practice patient survey and engagement with the community.
• 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.
• On the day of inspection patients told us they found the appointment system easy to use and were very happy with the care and treatment they received.
• There was a renewed focus on support, development and continual improvement at all levels of the organisation.

We saw areas of outstanding practice:

• In response to a significant event in another area, the practice had developed ‘grab cards’ for clinical and non-clinical staff to be used in the event of an emergency. The cards detailed the action that each responding member of staff would take to manage the emergency efficiently. Alongside this; we saw that the emergency equipment was clearly labelled with large numbers which corresponded to charts displayed throughout the practice. This meant that in stressful emergency situations, non-clinical or unfamiliar staff could be directed to collect a piece of emergency equipment, regardless of their knowledge of what that equipment looked like.
• The practice had introduced a dedicated pain management clinic in response to initiatives to reduce the prescription of pain medications. The consultations focused on enabling self-management of pain using alternatives to medications and also health promotion, using various resources like leaflets, social prescribing and websites.

The areas where the provider should make improvements are:

• The provider should continue to review and take steps to improve the uptake of cancer screening at the practice, including bowel, breast and cervical screening.
• The provider should review and improve their arrangements for patients who may wish to see a female GP.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice.

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall. (The previous inspection was on 5 November 2014 and the practice was rated as Good.)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The practice was rated as requires improvement for providing safe, caring, responsive and well led care. The issues identified as requiring improvement overall affected all patients.

The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced comprehensive inspection at Primrose Surgery on 9 November 2017 as part of our inspection programme.

At this inspection the key findings were as follows:

• We saw Patient Group Directions (PGDs) had been adopted by the practice to allow the nurse to administer medicines in line with legislation but we found that these had not been signed by the authorising body. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.)
• Significant events were not always discussed, analysed or reviewed in a timely manner at team meetings. We were not assured that when a patient was involved in a significant event, they received an apology and an explanation of what steps had been taken to prevent the same thing happening again.
• Practice meetings were held infrequently at approximately six monthly intervals, as were clinical meetings. We were told that the practice did not hold partners’ meetings or meet with members of the multi-disciplinary team, such as health visitors, midwifes, and safeguarding colleagues or meet to review those patients with palliative care needs.
• The practice made reasonable adjustments when patients found it hard to access services. For example, the practice had purchased a mobile phone to enable them to communicate effectively by text message with patients who were hard of hearing.
• The provider was unable to demonstrate that staff training, which would ensure that the team were suitably skilled and qualified to carry out their duties, was up to date or completed. We were not assured that regular appraisals were taking place or that they were effective. The staff induction process was poor.
• To support National self-care week the practice had invited a carers’ association, a cancer support charity and a local children’s centre into the practice to meet and inform patients of additional support services.
• The practice did not keep a record of the immunisation status of the staff team; in line with the guidance ‘Immunisation against infectious disease’ (‘The Green Book’ updated 2014.)
• Patient comment cards we received on the day were positive. However, responses to the National GP patient satisfaction survey 2017 were on average, 10% under the national average. Comments from patients we spoke with on the day were mixed.
• The majority of patients we spoke with reported they struggled to contact the practice by telephone to make appointments when they needed them. The practice showed us clear plans to update the system.
• The practice had a good knowledge of the needs of the local population and care was tailored to respond to this.
• Systems that were in place to manage risk were not always effective. For example, the practice had failed to ensure that window blinds in some clinical areas were compliant with the appropriate EU regulation (Directive 2001/95/EC) and posed a choking hazard.
• The practice had a number of policies and procedures to govern activity. However, a small number of these were not dated or were awaiting sign off from the GPs. On the day of inspection the management team had difficulty locating some policies.

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

• The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• The provider must ensure that care and treatment is provided in a safe way for service users.

The areas where the provider should make improvements are:

• The provider should review the management of, and response to, complaints in line with best practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced inspection visit on 5th November 2014. The overall rating for the practice was good.

Our key findings were as follows:

• Where incidents had been identified relating to safety, staff had been made aware of the outcome and action taken where appropriate, to keep people safe.
• All areas of the practice were visibly clean and where issues had been identified relating to infection control, action had been taken.

• Patients received care according to professional best practice clinical guidelines. The practice had regular information updates, which informed staff about new guidance to ensure they were up to date with best practice.

• The service ensured patients received accessible, individual care, whilst respecting their needs and wishes.

• We found there were positive working relationships between staff and other healthcare professionals involved in the delivery of service.

We saw several areas of outstanding practice including:

• The practice actively supported patients who may be vulnerable, including homeless and travelling people.
• The practice used translated notices and colour coded signage to assist patients whose first language was not English.

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

• The practice did not complete all the checks to ensure staff were safe to work at the practice. We found staff recruitment procedures were not effective and should be reviewed.

Professor Steve Field CBE FRCP FFPH FRCGP