Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Red Suite on 3 May 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Red Suite on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 2 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 May 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:

• Blank prescription forms and pads were stored securely and the practice had introduced a system that monitored their use.

• Significant improvements had been achieved in patient outcomes. The practice had continued to implement as well as further develop action plans to achieve and continue these improvements.

• The practice had revised the system that helped to ensure all governance documents were kept up to date.

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

The provider should:

• Continue to implement and monitor the effectiveness of the action plans to help ensure continued improvements to the quality of care provided for all patient population groups.

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 Red Suite on 3 May 2016. Overall the practice is rated as requires improvement. This inspection was a follow-up of our previous comprehensive inspection which took place in June 2015 when we rated the practice as inadequate overall. In particular the practice was rated as good for providing caring services, inadequate for providing effective and well-led services and requires improvement for providing safe and responsive services. The practice was placed in special measures for six months.

After the inspection in June 2015 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced focussed inspection in February 2016 to check that the practice had followed their plan and confirmed that they had complied with the enforcement action taken.

The inspection carried out on 3 May 2016 reflected that the practice had maintained the improvements found at the focussed inspection in February 2016. The practice had responded to the concerns raised at the June 2015 inspection and was continuing to implement their action plan in order to comply with the requirement notice issued.

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 for reporting and recording significant events.
• Blank prescription forms and pads were securely stored. However, the practice was unable to demonstrate there were systems to monitor their use.
• Risks to patients were 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.
• Data showed patient outcomes were low compared to the local clinical commissioning group (CCG) average and national average. However, the practice had an ongoing action plan to address this and continue to maintain and improve patient care.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• 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 a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• Practice specific policies were implemented and were available to all staff. However, the practice was unable to demonstrate they had an effective system to help ensure all governance documents were kept up to date.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure there is a system to monitor blank prescription forms.

• Continue to implement and monitor the effectiveness of the action plan to ensure improvement to the quality of care provided for all patient population groups continues.

In addition the provider should:

• Revise governance processes and ensure that all documents used to govern activity are up to date.

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 Red Suite on the 11 June 2015.

The practice was rated as inadequate and was placed in special measures. Practices placed in special measures are inspected again within six months. If insufficient improvements have been made and a rating of inadequate remains 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 practice 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 practice the reassurance that the care they get should improve.

Additionally, a breach of the legal requirements was found because systems and processes had not been established and operated effectively. As a result, the provider was not assessing, monitoring and improving the quality and safety of the services provided and mitigating the risks related to the health, safety and welfare of service users and others. Therefore, a Warning Notice was served in relation to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance.

Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breach and how they would comply with the legal requirements, as set out in the Warning Notice.

We undertook this announced focused inspection on the 11 February 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. The practice was not rated as a consequence of this inspection. As the practice is in special measures, it will be inspected again, with a view to assessing the practices rating when the timescale for being placed into special measures has passed.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by using the link for Red Suite on our website at:

http://www.cqc.org.uk/location/1-545262427

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 Red Suite on 11 June 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing effective and well-led services and it required improvement for providing safe and responsive services. The concerns that led to these ratings applied to all the population groups. It was therefore inadequate for providing services for older people, people with long-term conditions, families, children and young people, working age people (including recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). It was good for providing caring services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded and addressed.
• Staffing levels had not always been maintained and kept under review to ensure the needs of patients were appropriately managed and met, including keeping administrative tasks up-to-date.
• Risks to patients were assessed, although systems were not always implemented to manage identified risks, including recruitment checks, and safety audits in relation to infection control.
• Clinical audits had been carried out to help drive and improve patient outcomes.
• There was insufficient assurance to demonstrate that patients’ health care needs were effectively managed, as there was limited data to demonstrate how the practice managed, supported and met the on-going care and treatment needs of patients.
• 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 was available and easy to understand, although the practice complaints procedure had not been displayed within the practice.
• Urgent appointments were usually available on the day they were requested. Patients said that routine appointments were usually easy to get with the GPs, although they sometimes had to wait beyond their appointment times.
• The practice had a number of policies and procedures to govern activity and these were mostly in-date.
• The practice did not have a patient participation group (PPG), although feedback from patients was sought in other ways.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure the governance arrangements include systems and processes to audit and monitor the quality and safety of the services provided, including systems to demonstrate and provide assurance of how patients’ health care needs are managed, supported and met.
• Ensure the governance arrangements include audits to monitor staff training, infection control, and keeping the business continuity plan updated.
• Ensure the governance arrangements include a system to maintain and deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff, to effectively support and meet the needs of patients, including all clinical and administrative tasks.

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

Our inspection on 17 June 2014 found that patients were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements to manage medicines.

A compliance action was set asking the provider to take action regarding this concern. They wrote to inform us that they had taken action to rectify the area of concern found at this inspection.

We followed up on our inspection of 17 June 2014 to check that action had been taken to meet the compliance action set. We found that The Red Suite was able to demonstrate that they were meeting the compliance action set in order to rectify the area of concern identified at that inspection.

Our inspection on 2 September 2013 found that the Red Suite did not have appropriate measures in place to ensure that suspected abuse was dealt with properly. We checked the arrangements for the storage and monitoring of medication at the service and found that this was inadequate. There had been no reconciliation of drug stocks and the monitoring and storage of prescriptions was inappropriate. Staff had not received regular training and updates and there was an inadequate appraisal system in operation. We also found that policies and protocols had not been regularly reviewed by the service.

Compliance actions were set asking the provider to take action regarding these concerns. They wrote to inform us that they had taken action and put measures in place to rectify the areas of concern found at this inspection.

We followed up on our inspection of September 2013 to check that action had been taken to meet the compliance actions set. We found that The Red Suite was able to demonstrate that they were meeting all but one of the compliance actions set in order to rectify the areas of concern identified at that inspection. We found that the reconciliation of drugs stocks and the monitoring and storage of prescriptions still required further improvement.

The service was run by three GPs who had two nurses to assist with minor operations, the care of people with chronic conditions and immunisations. A late evening appointment service was available once a week. People told us: " There are never any problems getting an appointment". Other people said that they could always see a GP on the same day if they needed to. We found that medical records contained full details about people's conditions and treatment together with any known allergies. The people we spoke with described the service as : " Helpful and approachable" and said they were satisfied with their care.

We found that the service did not have appropriate measures in place to ensure that suspected abuse was dealt with properly. Staff had not all received safeguarding training and there was no adult protection policy.The service was clean and had systems in place to protect people and staff from the risk of the spread of infection.We checked the arrangements for the storage and monitoring of medication at the service and found that this was inadequate. There had been no reconciliation of drug stocks and the monitoring and storage of prescriptions was inappropriate.

Staff had not received regular training and updates and there was an inadequate appraisal system in operation. We found that policies and protocols had not been regularly reviewed by the service.

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Requires Improvement

We carried out an announced comprehensive inspection at Red Suite on 19 November 2018 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:

• There was an effective system for reporting and recording significant events.
• There was an effective system to manage infection prevention and control.
• The arrangements for managing medicines in the practice kept patients safe.
• Staff did not always have the information they needed to deliver safe care and treatment to patients.
• The practice ensured that care and treatment was delivered according to evidence- based guidelines. However, it did not make effective use of the clinical system to identify patients with long tern conditions, such as diabetes, and offer them the best treatment for their condition.
• Performance for diabetes, asthma and most other long-term conditions for 2017 / 2018 was below local and national averages.
• The practice’s uptake for cervical, breast and bowel screening cancer was below local and national averages.
• Staff treated patients with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the practice within an acceptable timescale for their needs. Patients were not satisfied with the ease with which they could contact the practice by phone. Patients were not able to book appointments or order repeat prescriptions on line.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.
• The practice’s processes for managing risks, issues and performance were not always effective.

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:

• Continue to review telephone access for patients
• Continue with the process of introducing a system of online services to patients in line with the practice’s contract with NHS England.

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.