This practice is rated as Good overall. (Previous rating February 2018 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Not inspected on this occasion

Are services caring? – Not inspected on this occasion

Are services responsive? – Not inspected on this occasion

Are services well-led? - Not inspected on this occasion

We carried out an announced comprehensive inspection at Sidley Medical Practice on 09 January 2018. The overall rating for the practice was good. The practice was also rated good for the effective, caring, responsive and well-led domains and all the population groups. It was however rated as requires improvement for providing safe services. The full comprehensive report on the January 2018 inspection can be found by selecting the ‘all reports’ link for Sidley Medical Practice on our website at www.cqc.org.uk

After the inspection in January 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced focused inspection carried out on 14 August 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 on 09 January 2018. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

At this inspection our key findings were:

The practice had introduced a system to help ensure that an explanation of any anomalies in fridge temperatures, and any actions taken, were recorded.

The system for checking and recording the expiry dates of emergency medicines had been reviewed and improved. All emergency medicines we checked were within their expiry dates.

Additionally, we saw that:

The practice was in the process of introducing a system that would allow them to record online and face to face training in one place.

Changes had been made to recruitment processes that ensured the practice obtained explanations of periods of gaps in employment from applicants.

All patients had a named accountable GP and access to the full range of services offered by the practice including online services.

Changes had been made to the systems and processes involved in chronic disease management (including mental health).

The practice showed us evidence (not yet verified by the CQC data team) that they were meeting the 90% target for all childhood immunisations.

The areas where the provider should make improvements are:

Consider making all operational documents readily accessible to all appropriate staff.

Review and improve the systems for checking emergency equipment to help ensure out of date items are removed in a timely manner.

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

This practice is rated as Good overall. (Previous rated inspection 16 June 2017 – Requires Improvement.)

The key questions 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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those retired and students – Good

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Sidley Medical Practice on 9 January 2018 to follow up on breaches of regulations. The practice was inspected initially on 23 August 2016 and found to be in breach of the regulations. At a follow up inspection on 16 June 2017 the practice was still found to be in breach of the regulations and a warning notice was issued in line with our enforcement policy. On 21 August 2017 the practice was again inspected to ensure that the terms of the warning notice had been complied with and we found that sufficient improvement had been made to comply with the warning notice. This inspection was not rated.

At this inspection we found:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. When incidents did happen, the practice learned from them and improved their processes.
• The practice had systems in place to review the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to evidence- based guidelines.
• The practice had reliable systems for the management of medicines with the exception of recording the temperatures of vaccine fridges and the checking of expiry dates of emergency medicines.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was reasonable access to appointments which could be booked in advance or were available on the day.
• The practice encouraged, and acted on, feedback from staff and patients, including via its complaints system. The provider was aware of and complied with the requirements of the Duty of Candour.
• The practice had reviewed its leadership and governance structure and staff felt supported by management.

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

Ensure that maximum, minimum and actual fridge temperatures are recorded with an explanation if found to be outside the agreed parameters.

Ensure medicines in the emergency kit are within date and available for use.

The areas where the provider should make improvements are:

Consider recording both online and face to face training in a single place.

Consider reviewing recruitment interview questions so that explanations of gaps in employment history are always asked about and recorded.

Consider what action to take to enable all patients to attain access to a named accountable GP and to the full range of services including online services.

Monitor and seek to improve any areas of chronic disease management, the management of mental health conditions and childhood immunisation rates that fall below the local and national average.

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 inspection of Sidley Medical Practice on 21 August 2017. This was to follow up on a warning notice the Care Quality Commission served following an announced focused inspection on 16 June 2017 when the practice was rated as inadequate for providing well led services.

The warning notice was served relating to regulation 17: Good Governance of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notice was 18 August 2017.

The June 2017 inspection highlighted several areas where the provider had not met the standards of regulation 17: Good governance. These included:

• Clinical audits did not demonstrate quality improvements to patient care.
• Staff training and appraisals did not ensure all staff had received up to date training or were aware of their learning needs.
• Patient safety and medicines alerts were not effectively managed and the practice could not provide evidence they had reviewed all alerts in a comprehensive way.
• The practice was unable to evidence they had reviewed and completed all the highlighted actions in the infection control audit. Cleaning records did not include items of medical equipment and the practice could not demonstrate regular cleaning of medical equipment took place.
• Not all staff were aware of how to identify and report a significant event.
• Governance arrangements did not ensure background checks were carried out for staff prior to employment.
• The practice had failed to seek and act on feedback from staff and had failed to identify that many staff were unaware of the practice vision and business plan.

At this inspection in August 2017 we found that actions had been taken to improve the provision of well led services. Specifically the practice had:

• Reviewed the governance arrangements for all areas of practice outlined in the warning notice.
• Held a meeting with all staff to offer training on significant events to provide an understanding of their role and the terminology.
• Improved the arrangements for dealing with patient and safety alerts received from various sources, including the Medicines and Healthcare Products Regulatory Agency (MHRA).
• Reorganised the staffing structure and assigned a new designated staff lead to deal with personnel and recruitment documentation.
• Allocated protected time for staff to undertake essential training such as safeguarding, fire safety and information governance.
• Commenced or completed staff appraisals for all staff that had been in post for over 12 months.
• Reviewed the infection control action plan and ensured all outstanding actions had been completed or had a date specified for completion within a reasonable timeframe. Cleaning records demonstrated clinical equipment was being regularly cleaned and checked.
• Undertaken further clinical audits and demonstrated improvements to patient care and outcomes.
• Improved communication with staff at all levels and actively engaged with their ideas and suggestions for developing the practice.

At our previous inspection in June 2017, we rated the practice as inadequate for the provision of well-led services and an overall rating of requires improvement. At this inspection we have focused on the warning notice findings in respect of the well led section of our report. We found that the practice had taken action to address the breaches of regulation set out in the warning notice issued in July 2017. However, the current ratings will remain until the practice receives a further comprehensive inspection to assess the improvements achieved against all breaches of regulation identified at the previous inspections.

The focused report published on 28 July 2017 should be read in conjunction with this report.

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 Sidley Medical Practice on 23 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Sidley Medical Practice on our website at www.cqc.org.uk.

This was an announced focused inspection carried out on 16 June 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 23 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• There was no formalised process for reviewing, assessing risk and taking action for patient and medicine safety alerts. There was no record of previous alerts that had been acted on and an alert from April 2017 was yet to have actions taken.
• Not all staff were aware of the process for reporting and recording significant events. Learning from events was shared with staff directly involved or disseminated through line managers.
• There were gaps in staff training. Some clinical and non-clinical staff had not received adult safeguarding training and one non-clinical member of staff had not received child safeguarding appropriate to their role. Some staff still had not received training in fire safety and information governance.
• Recruitment procedures had improved, although references for one member of clinical staff had not been requested prior to employment.
• Staff appraisals had been commenced but not all staff, who were eligible, had received an appraisal in the last 12 months.
• The practice had undertaken some clinical audits but there was little evidence of improvements to the quality of patient care.
• An infection control audit, carried out in March 2017, did not identify interventions required, which member of staff was responsible and a timescale for action. Completed actions were not documented.
• Care plans were available for a variety of long term condition management but not all clinical staff accessed or used them.
• There was a lack of awareness of the practice vision and business plan amongst staff and not all staff felt involved in discussions about how to run and develop the practice.
• Patient group directions and patient specific directions were administered in line with legislation.
• Practice policies were practice specific and up to date.
• The practice had designated a GP as the overall clinical lead and other GP partners had been assigned lead roles.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

In addition the provider should:

• Ensure that alerts for children and adults at risk which are placed on the practice computer are also placed on family or other household members’ records, as appropriate.

At our previous inspection on 23 August 2016, we rated the practice as requires improvement for providing safe, effective and well led services. The arrangements for reviewing and implementing action for patient and medicine safety alerts, staff awareness of significant event reporting and processes, infection control audit documentation, staff recruitment files, staff training records, appraisals and clinical audits were ineffective.

At this inspection we found that sufficient improvements had still not been fully introduced or implemented. Consequently, the practice is rated as requires improvement for providing safe and effective services and inadequate for well led services.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

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 Sidley Medical Practice on 23 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.
• 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.
• There was an open and transparent approach to safety and a system in place for reporting significant events, although we found the process could be improved. This included that not all staff were aware of how to report significant events, the recording was not always complete and the learning was not always shared to improve patient care.
• Most risks to patients were assessed and well managed. However, some systems and processes to address risks were not implemented well enough to ensure patients and staff were kept safe. This included the arrangements to manage infection control, the completion of recruitment checks, and that safeguarding training had not been completed by all staff.
• 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 and there was continuity of care, with urgent appointments available the same day. The patients we spoke with on the day of the inspection who told us they were happy with the care and treatment they received.
• 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, but not by all members of the senior management team. We found a lack of clinical input into the running and direction of the practice as there was no clinical lead.
• The practice had a number of policies and procedures to govern activity, but some had not been dated or were not practice specific.
• The provider was aware of and complied with the requirements of the duty of candour.
• The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active and had made a number of improvements to the practice and ensured regular communication with the patients.

The areas where the provider must make improvements are:

• Ensure that there are clear processes for reporting, recording, acting on and monitoring significant events, incidents and near misses that are understood by all staff. Ensure that lessons learnt from complaints and significant events are communicated to the appropriate staff to support improvement at all levels.
• Ensure that all documents and processes used to govern activity are practice specific and up to date. This includes adult safeguarding arrangements, and the use of both patient group directions and patient specific directions when authorising clinical staff to administer vaccines and medicines.
• Ensure there are formal pathways to seek, act and monitor all relevant and current evidence based guidance and standards. This includes the National Institute for Health and Care Excellence (NICE) best practice guidelines and patient safety alerts.
• Ensure all the learning and development needs of all staff are identified and addressed through a system of comprehensive annual appraisals. Ensure all staff are up to date with training appropriate to their job role; including adult and child safeguarding, fire awareness and information governance.
• Ensure there are clear and formal arrangements in place to assess the risk of, prevent, detect and control the spread of infections. This includes that actions from infection control audits are completed and recorded. Ensure that the cleaning of medical equipment and fabric curtains is undertaken, recorded and monitored.
• Ensure recruitment procedures are established and operated effectively to satisfy that staff employed are of good character, such as obtaining references as set out in the practice recruitment policy.
• Ensure the risks to the health and safety of patients and staff has been assessed and mitigated where reasonably possible, by conducting and recording fire drills at least annually, to include whole practice evacuation.
• Ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services being provided by developing an on-going audit programme in a range of clinical areas.
• Ensure that effective and timely care planning takes place to ensure the health, safety and welfare of patients. Communicate the methods to store and locate patient care plans to all clinical staff.
• Improve the mechanisms for all staff to raise concerns; ensuring consistent support and mentorship is available from all members of the management team. Formally communicate to all staff the practice governance, vision, strategy and supporting business plan.

In addition the provider should:

• Allocate and define a role of clinical lead.
• Ensure that alerts for children and adults at risk which are placed on the practice computer are also placed on family members’ records, as appropriate.
• Review the visibility of signage to inform patients of the availability of chaperones, to include all treatment rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice