Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Southview Park Surgery on 13 July 2016 and a follow up focused inspection on 01 March 2017. At our July 2016 inspection the practice received a good rating overall. It achieved a good rating in effective, caring, responsive and well-led services and requires improvement for providing safe services. At our follow up inspection in March 2017 the practice had made sufficient improvement for providing a safe service but required improvement for providing effective services. Overall the practice was rated as good in March 2017. A good rating was achieved in safe, caring, responsive and well-led however the effective domain required improvement. The July 2016 and March 2017 reports can be found by selecting the ‘all reports’ link for Southview Park Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 31 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 01 March 2017. A requirement notice was issued for improving governance in relation to quality improvement processes. This report covers our findings in relation to those requirements.

The practice is now rated as good for providing effective services. During our October 2017 inspection we found:

• The practice had changed their quality improvement processes and had introduced a clinical lead to provide oversight and identify the areas of clinical practice which benefited from being reviewed.

• The practice had conducted four audits since the last inspection to improve clinical practice. The audits identified clear aims, portrayed results and analysis in order to drive quality improvement.

• Quality improvement processes were discussed at monthly team meetings and more regularly between the clinical lead and the practice manager.

• We found areas of improvement and future change as a result of their findings.

• The practice had discussed and documented risks in relation to the medicines patients were prescribed. We saw discussions were noted within patients’ medical records.

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 Southview Park Surgery on 13 July 2016. The overall rating for the practice was good. A good rating was achieved in effective, caring, responsive and well-led. A requires improvement rating was achieved for providing safe services. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Southview Park Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 01 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 13 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good as we found sufficient improvements had been made in the safe management of medicines.

At our initial inspection of the practice in July 2016 we found that the provider did not have systems established to ensure safety alerts such as Medicines and Healthcare products Regulatory Agency (MHRA) were appropriately actioned. A requirement notice was issued to ensure the provider made suitable improvements for these risks.

The practice was also asked to consider:

• Improving comprehensive documentation and analysis of significant incidents, including identifying potential detriment to patients, staff or public. Actions identified should be reviewed to ensure their effective implementation.

• Implement a quality improvement process including clinical audit, aligning them to national and local guidelines. Ensure areas for improvements are actioned and shared with practice staff.

• Consider joint clinical meetings with the GPs and practice nursing team. Ensure these are accurately recorded and reflect actions identified and their completion.

• Improve national cancer screening rates for patients.

• Review and reduce the attendance of patients at A&E departments.

• Ensure cleaning schedules reflect the full extent of activities undertaken.

During our March 2017 inspection we found:

• The practice had revised their system for managing patient safety and medicine alerts. We revisited the previous medicines searches and found the practice had a system in place to identify, review and address the needs of patients so they no longer remained at risk. Although we found the system to be effective two patient records we looked at did not contain detail that the risks had been dicussed with patients.

• The practice presented us with three audits but these all related to the monitoring of medicines. We reviewed these audits and found there had been a lack of clinical oversight. The analysis of these audits did not contain sufficient detail to identify where the practice might improve or the subsequent actions to take. Since the last inspection there was no evidence of any other quality improvement processes in place including clinical audit.

• The practice had revised their system for identifying, investigating and responding to significant incidents. We found that the system in place was now effective.

• The practice actively promoted national cancer screening programmes during consultations. The practice’s uptake for the screening of women age 50-70 years for breast cancer in the last 36 months had improved. The practice screening of women age 50-70 years for breast cancer in the last 36 months was previously 61% and had increased to 65% which was comparable to the CCG average of 69%.

• The practice had established joint clinical meetings. We looked at the minutes from the last two meetings held, dated 12 August 2016 and 11 November 2016. They were well attended by the clinical team and learning outcomes and actions were clearly documented and revisited.

• The practice followed up with patients who attended A&E to ensure their needs were being met and to mitigate their need to re-attend.

• The practice had revised their cleaning schedules for equipment and clinical rooms. These were dated and included details of how items were to be appropriately cleaned. All were overseen by the practice manager.

Action the service MUST take to improve:

• Implement a quality improvement system at the practice to include clinical and non-clinical audit and where improvements have been identified these should be shared with relevant staff.

Actions the service SHOULD take to improve:

• Ensure that where risks are identified in relation to the medicines patients are prescribed, these are discussed with the patients concerned and recorded in their medical records.

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 Southview Park Surgery on 13 July 2016. Overall the practice is rated as good.

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

• Staff had confidence in reporting, recording, investigating and responding to significant events. However, the practice acknowledged improvements could be made to improve the detailing of the incidents, analysis, response and revisiting of lessons learnt.
• The practice had systems in place to share patient safety and medicines alerts but did not have systems established to ensure they were appropriately actioned. The searches were not revisited to ensure safe prescribing and the management of medicines.
• The practice appeared clean and tidy. An annual infection control audit had been conducted and cleaning schedules were in place but did not accurately reflect the full extent of actions undertaken.
• There were limited quality improvement processes, including clinical audit, in place at the practice.
• We found appropriate recruitment checks had been undertaken prior to employment.
• Staff were supported to have the skills, knowledge and experience to deliver effective care and treatment.
• Staff received detailed inductions, probationary reviews and yearly appraisals. The practice identified and addressed the development and training needs of their staff.
• Data from the national GP patient survey showed patients rated the treatment by the practice nurses as higher than the local and national averages. However, the reviews were less favourable of the GPs.
• Patients were able to book appointments in person, over the phone and on line.
• Some patients reported difficulties making convenient appointments. However, on the day urgent appointments and telephone appointments were available.
• There was a defined leadership structure in place, with assigned roles and responsibilities and staff appointed to act in each other’s absence.
• Patients told us of the kind and welcoming reception they received from staff. We saw staff were polite, respectful and supportive to one another.
• The practice attended Basildon and Brentwood Clinical Commissioning Group events and participated in local pilot schemes.

The areas where the provider must make improvement are:

• Ensure patient safety and medicines alerts are appropriately actioned and revisited to ensure the safe prescribing and management of medicines.

The areas where the provider should make improvement are:

• Improve the comprehensive documenting and analysis of significant incidents, including identifying potential detriment to patients, staff or public. Actions identified should be reviewed to ensure their effective implementation.
• Implement a quality improvement process including clinical audit, aligning them to national and local guidelines. Ensure areas for improvements are actioned and shared with practice staff.
• Improve national cancer screening rates for patients.
• Review and reduce the attendance of patients at A&E departments.
• Ensure cleaning schedules reflect the full extent of activities undertaken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice