This practice is rated as Good overall. (Previous inspection was on 18 August 2016 – the practice was rated good overall and requires improvement in well led)

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

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 recently 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 South Axholme Practice on 18 August 2016. The overall rating for the practice was good and requires improvement in well led. The full comprehensive report for the August 2016 inspection can be found by selecting the ‘all reports’ link for South Axholme Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive carried out on 20 March 2018 to check whether the provider was now 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. This inspection looked at the five key questions of safe, effective, caring, responsive and well led.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• 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.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Review the process for calibration of the thermometers used to monitor room temperatures.

• Monitor that the practice’s standard operating procedure for stock checks of medicines is followed.

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 South Axholme Practice on 2 February 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be inadequate for providing safe services and requires improvement for providing effective and well led services. The practice was good for caring and responsive services. It also required improvement for providing services for all of the six population groups based on the concerns identified under safe.

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

• Aspects of safe practice were not in place. For example, criminal record checks through the disclosure and barring service (DBS) were not always undertaken prior to staff commencing their employment.  We also found that medicines were not always well managed.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed, although in one instance was not sustained.

• Data showed patient outcomes were mostly at or above average nationally. Staff referred to guidance from the National Institute for Health and Care Excellence and patient’s needs were assessed and care was planned and delivered in line with current legislation. The practice was identified as high risk for the prescribing of one specific type of medicine and the practice was receiving external support to reduce this.

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

• Information about services and how to complain was available.
• The majority of patients were satisfied with the appointment system. Negative comments mostly related to the ability to see their GP of choice.
• The practice proactively sought feedback from staff and patients.
• Staff were supported to carry out their role. However, the nursing staff did not receive formal clinical supervision and the health care assistant did not have their delegated areas of responsibility competency assessed.

The areas where the provider must make improvements are:

• Ensure all necessary employment checks (including criminal records checks from the DBS) are obtained for staff before they commence work. 
• Ensure risk assessments are undertaken for employee roles which do not require a criminal records check from the DBS.

• Ensure arrangements are in place for the safe management of medicines.

In addition the provider should:

• Ensure that systems are in place for the security of patient records when outside of the practice.
• Ensure that arrangements are in place for the nursing staff to receive formal clinical supervision and for the health care assistant to have their delegated areas of responsibility competency assessed.
• Ensure the practice participates in external peer review or benchmarking with practices, locally or nationally to compare the practices performance to others.
• Ensure that arrangements are in place for risk assessing legionella.
• Ensure arrangements are in place to check that measures introduced following incidents are maintained or evaluated for the effectiveness.
• Ensure that systems are in place to record and identify training that is due and overdue in order that all staff can complete mandatory training in a timely way.
• Ensure the practice acts on the advice of other agencies in a timely way.
• Ensure the practice management have an understanding of the Regulations relating to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 from April 2015.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

The practice was previously inspected on 2 February 2015 and the overall rating was Requires improvement.

We carried out an announced comprehensive inspection at South Axholme Practice on 18 August 2016. Overall the practice is now rated as good.

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. However, when things went wrong, the learning from reviews and investigations was not always embedded.

• Risks to patients were not always assessed and well managed. There was no documented evidence of national patient safety alerts having been actioned.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• 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. Some improvements were made to the quality of care as a result of complaints and concerns but these were not shared with all staff and embedded.

• Patients said access to a named GP and continuity of care was not always available quickly, although urgent appointments were usually 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 practice had policies and procedures in place. However, we found some procedures were not always followed in terms of the recruitment of staff and the management of some medicines.

The areas where the provider must make improvements are:

• Ensure arrangements are in place for the safe management of some medicines.

• Ensure recruitment arrangements include obtaining two references for all staff.

The areas where the provider should make improvement are:

• Check that measures introduced following incidents are maintained and evaluated for effectiveness.

• Review the frequency of basic life support training to ensure it follows best practice guidelines as laid down by the Resuscitation Council (UK).

• Ensure action is taken to proactively identify carers registered at the practice.

• Review the arrangements in place for the safe management of sterile equipment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice