Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 30 March 2016. We set a requirement in relation to safe care and treatment. The practice sent in an action plan informing us about what they would do to meet legal requirements in relation to the following:

• The appropriate storage and recording of controlled drugs.
• The system for ensuring changes to prescriptions recommended by secondary care were checked and authorised by a GP.
• Improving the prescribing protocol to ensure GPs had good oversight of prescribing to patients, including dates for medicines reviews. For example, those patients using salbutamol or thyroxine.

We undertook a follow up inspection visit on 19 December 2016 to make a judgement about whether the actions had addressed the requirements.

• Improvements had been made in relation to the storage and recording of controlled drugs.
• Procedures were followed appropriately when patient’s medicines were changed following discharge from hospital or outpatient appointments.
• The practice had set out plans to monitor and assure the quality of its dispensing service.
• The practice’s repeat prescribing policy had been appropriately reviewed.

• The practice needs to continue to ensure GPs have good oversight of prescribing to patients, ensuring reviews for patients on medication are undertaken timely.

• The practice had reviewed and amended their protocol around recruitment checks.
• A review of the legionella assessment findings was carried out internally and remedial work had been carried out shortly after the inspection in March 2016.
• A medication review system flowchart was introduced for all staff involved in the process of medication reviews. The practice had also implemented a policy to support staff in the process of exception reporting for the QOF (Quality and Outcomes Framework, a voluntary incentive scheme for GP practices in the UK. The scheme financially rewards practices for managing some of the most common long-term conditions e.g. diabetes and implementing preventative measures. The results are published annually.).

The area where the provider should make improvement is:

• Continue to strengthen the systems for ensuring GPs have good oversight of prescribing to patients, ensuring reviews for patients on medication are undertaken in a timely way
• Continue to review QOF exception reporting levels and to try and reduce this to improve the health and wellbeing of patients

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for on our website at www.cqc.org.uk

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 Saxmundham Health on 30 March 2016. Overall the practice is rated as good.

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 assessed patients’ needs and delivered care in line with current evidence based guidance but improvement was needed for the prescribing protocol and associated procedures.
• 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.
• 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.
• 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.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make an improvement is:

• Controlled drugs held within the practice other than in the controlled drugs’ safe, for example in GP bags, were not properly registered in line with the same regulations. The practice must ensure in follows legislation for controlled drug storage at all times.

• Prescriptions were reviewed and signed by GPs before they were given to the patient, however, following discharge from hospital and outpatient appointments dispensers made changes to patient’s medicines which were not checked by GPs to ensure safety. The practice must ensure this takes place in all instances.

• Improve the prescribing protocol to ensure GPs have good oversight of prescribing to patients, including review dates for patients on medication. For example, for those patients using salbutamol or thyroxin we noticed a number of reviews were overdue.

The areas where the provider should make improvements are:

• Ensure that staff who access and use patient sensitive data have received a Disclosure and Barring Service (DBS) check or have a written risk assessment completed.
• Whilst an external legionella risk assessment had been undertaken, required actions that were raised had not been addressed despite the assessment taking place in May 2015.
• Improve patient recall systems, consistently code patient groups and produce accurate performance data.

We saw one area of outstanding practice:

• The practice was very proactive in trialling and delivering innovative projects that aimed to improve patients’ care, knowledge and experiences. The local CCG confirmed this was the case and considered the practice’s approach to innovation to be very positive. Not all proposed projects had come to fruition or had been successful but several had been and were (or had been) active in the practice’s area. Amongst others there were for example, “Advice Letter Listing (ALL)”, "Instantcare" and "i-Van".

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

The practice is rated as requires improvement overall. The practice was previously inspected in December 2016 and rated as good.

The key questions at this inspection are rated as:

Are services safe? –Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Saxmundham Health on 20 February 2019 as part of our inspection programme.

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, and good for all population groups, with the exception of people with long-term conditions, which we rated as requires improvement. At this inspection we found:

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to evidence-based guidelines; this was undertaken on an individual clinician basis, as the practice did not have a system or process to share this.
• Staff involved and treated patients with compassion, kindness and dignity and patients were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

We rated the practice as inadequate for providing safe services because:

• The practice issued medicines against unsigned prescriptions and did not have a safe process in place for ensuring the final dispensed prescription was correct. Following the inspection, the practice introduced a process for ensuring prescriptions were signed before they were dispensed to patients and for double checking that dispensed medicines were correct. These processes needed to be embedded.
• There were 263 patient records which had not been summarised. Following the inspection, the practice advised there was an eight-month backlog. The practice was aware of the backlog and had employed an additional temporary member of staff, who had since left. The summariser role also included the role of financial assistant and occasional scanning, so summarising was undertaken on an ad hoc basis. The practice planned to review administration job descriptions and hours to allow dedicated workforce hours to summarising and to recruit if necessary and viable.
• Information about safety was not always comprehensive or timely. The identified actions from the fire and health and safety risk assessments, infection control audit and significant events were not monitored to completion. Although some actions had been completed, these were not always documented.
• The actions identified for significant events were not always effective in reducing the likelihood of reoccurrence, particularly in relation to the dispensary.
• The Hepatitis B status of some clinical staff was not known and a risk assessment had not been undertaken for their role.
• There were no documented cleaning schedules or records of cleaning undertaken by practice staff.
• Training deemed mandatory by the practice had not been completed by all staff. This included safeguarding children, infection control, advanced life support, immunisation and fire safety training.
• The practice did not always review or act on patient safety alerts. We looked at three safety alerts, two from November 2018 and one from January 2018. There was no evidence of review in the patient records. Following the inspection, the practice submitted a new policy for receiving, reviewing and actioning alerts. They advised they would review patients who had been identified during the inspection as not having been reviewed following a safety alert.

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

• The governance processes for monitoring the completion of identified actions from the fire and health and safety risk assessments, infection control audit and significant events were not always effective. The practice was aware of this and were in the process of establishing and embedding new systems.
• The practice had established a new system for responding to and managing complaints, and monitoring the completion of training deemed mandatory by the practice, which needed to be embedded.
• Staff did not all feel supported or able to raise concerns without fear of retribution and responses to identified incidents did not always emphasise safety and the well-being of staff.

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

• The exception reporting for some of the Quality and Outcomes Framework (QOF) long term condition indicators were higher than the Clinical Commissioning Group (CCG) and England averages. Although the practice excepted patients in line with QOF requirements, a significant number of patients were not receiving the interventions and there was no action plan in place to address this.

The areas where the provider

must

make improvements are:

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

• Establish a system to keep clinicians up to date with evidence based practice.
• Continue work to improve the review of patients diagnosed with cancer.
• Arrange for appropriate staff to sign the standard operating procedures in the dispensary and monitor that staff are following them.
• Review the arrangements and work undertaken, particularly at the dispensary desk, to maintain patient confidentiality.

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