Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of St Margaret’s Medical Practice on 27 January 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment), 13 (Safeguarding services users from abuse and improper treatment), 17 (Good governance), and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook an unannounced focussed inspection on 10 October 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. During this inspection we found that some areas had been addressed but that some actions had not yet been put in place; we also found some further areas of concern, which required further investigation. Therefore, the decision was made to extend the focussed inspection to a full comprehensive inspection, and we returned to the practice for an announced visit on 1 November 2016 in order to consider the areas which had not been covered during the focussed inspection and to look in further detail into the further areas of concern we had noted.

Following the further inspections, the practice submitted an action plan, outlining the further actions that they would carry-out to address the additional issues identified. On 23 August 2017 we contacted the practice and asked them to send us evidence that they had followed their action plan, in order for us to undertake a focussed desk-based inspection. This information was received on 25 September 2017. This report covers our findings from the desk-based inspection of 25 September 2017. You can read the reports from the previous inspections by selecting the ‘all reports’ link for St Margaret’s Medical Practice on our website at www.cqc.org.uk.

Overall the practice was rated as requires improvement following the initial comprehensive inspection on 27 January 2016. They were rated as requires improvement for providing safe and effective services and for being well led. Following the re- inspection in October & November 2016 we rated the practice as good overall. We rated them as requires improvement for providing a safe service and good for providing an effective service and for being well led. The inspection of 25 September 2017 looked only at the safe domain and rated this as good.

Our key findings were as follows:

• The practice had been pro-active in identifying patients with caring responsibilities, in order to provide these patients with additional support. Since the last inspection in October and November 2016, the practice had begun using a carers’ template which helped staff to record all relevant details about patients with caring responsibilities on the practice’s patient database. They had also started to ask patients whether they were a carer when they registered with the practice, and provided a box in reception where patients could leave their details to identify themselves as a carer. As a result of these measures, the practice had increased the number of carers from 19 to 80 (0.8% of the patient population).
• During the previous inspection in October and November 2016 we found that the practice had failed to ensure that a complete and contemporaneous record was kept in respect of each service user. The practice was aware of performance issues in this area in respect of one member of staff, which were being addressed externally; however, in the meantime they had failed to put measures in place to assure themselves that patients were not being put at risk as a result of this. When we re-inspected in September 2017, we were shown evidence of the systems put in place to support the member of staff and monitor and review their patient consultation notes which demonstrated improvements.
• During the previous inspection we found that two members of staff had received training to be repeat prescribing clerks, but that written guidance was not in place. When we re-inspected we found that the practice’s prescribing policy had been updated to include guidance for administrative staff.
• Data showed patient outcomes were below the local and national average in some areas; however, results from the Quality Outcomes Framework showed the practice’s performance had improved during the 2015/16 reporting year compared to the previous year, and the practice had introduced measures to further improve during the current reporting year.

The areas where the provider should make improvement are:

• They should continue to pro-actively identify patients with caring responsibilities in order to ensure that these patients receive the support they need.
• They should continue to monitor and improve their performance in relation to patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGPChief

Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Margaret’s Medical Practice on 27 January 2016. Overall the practice is rated as requires improvement.

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, reviews and investigations were not thorough enough and there was a lack of evidence that lessons learned were discussed and shared.
• We saw examples of patients records not being kept up to date and lacking detail, and of formal care plans not being produced for patients who needed them.
• Risks to patients were in most cases assessed and well managed, however, we identified several areas where risks were not adequately addressed, for example, the practice could not provide evidence to show that all members of staff had been trained in child safeguarding to the required level; there were examples of new members of staff starting work without adequate background checks; the practice did not have a fire alarm, they also did not have an adequate plan in place to ensure that they could deal with medical emergencies.
• In some cases, staff were administering medicines without the appropriate legal authorisations.
• Data showed patient outcomes were below the local and national average. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• The majority of patients said they were treated with compassion, dignity and respect.
• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, but not all staff were aware of where these were kept.
• The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

• They must ensure that records of consultations and prescriptions are made in a timely way.
• They must ensure that they identify and address poor patient outcomes and their rate of exception reporting.
• They must ensure that all necessary employment checks are carried on staff.
• They must put in place the correct and up-to-date legal authorisations required for staff to administer medicines.
• They must ensure that a fire alarm is installed.
• They must ensure that they have a system in place to record and disseminate discussions and decisions to all relevant staff.
• They must ensure that all staff have completed mandatory training to the required level.
• They must ensure that testing of electrical equipment is carried-out annually.

In addition the provider should:

• Ensure that they have put in place care plans for patients who need them.
• Put in place formal mechanisms for multi-disciplinary team working.
• Ensure that all staff are aware of how to access practice procedures.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

People we spoke with who use the service told us they were happy with the service provided by staff at the practice. One person had been attending the practice for 25 years and their needs had recently changed significantly, and they said staff had been "extremely good" at accommodating them. Members of the patient participation group told us that they were able to raise concerns, and that the partners were "very responsive" to making changes which would improve the practice.

We observed that despite being very busy on the day of our inspection, reception staff were available to assist people in a timely manner, and were professional and polite. We found that when we sat in the reception area, we could not hear what was being said as people checked in for their appointments. We also could not hear what was being said when reception staff were on the phone. If patients were uncomfortable speaking to staff in the reception area, a separate private room was available.

We found that there were appropriate infection control measures in use at the practice and that medicines were adequately managed. We also found that people were protected from the risk of abuse because procedures were in place at the practice for safeguarding children and vulnerable adults, and staff demonstrated that they were aware of these procedures.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of St Margaret’s Medical Practice

on 27 January 2016

. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment), 13 (Safeguarding services users from abuse and improper treatment), 17 (Good governance), and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook an unannounced focussed inspection on 10 October 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements.

During this inspection we found that some areas had been addressed but that some actions had not yet been put in place; we also found some further areas of concern, which required further investigation. Therefore, the decision was made to extend the focussed inspection to a full comprehensive inspection, and we returned to the practice for an announced visit on 1 November 2016 in order to consider the areas which had not been covered during the focussed inspection and to look in further detail into the further areas of concern we had noted.

This report covers our findings from both follow-up inspections on 10 October 2016 and 1 November 2016. You can read the report from the initial comprehensive inspection by selecting the ‘all reports’ link for St Margaret’s Medical Practice on our website at

www.cqc.org.uk

.

Overall the practice was rated as requires improvement following the initial comprehensive inspection on 27 January 2016. They were rated as requires improvement for providing safe and effective services and for being well led. Following the re- inspection we found the practice to be requires improvement for providing a safe service and good for providing an effective service and for being well led.

Our key findings were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. During the initial inspection we found that reviews and investigations into significant events were not thorough enough and there was a lack of evidence that lessons learned were discussed and shared. During the re-inspection we saw evidence that significant events were well recorded and that they were discussed with staff at all levels as appropriate.

• Risks to patients were assessed and well managed. At the time of the initial inspection in January 2016 we found areas where the practice had failed to adequately mitigate risks to patients and staff; for example, they did not have means to raise the alarm in the event of a fire (at the time they were about to commence an extensive building programme which included the installation of a fire alarm; they had put some interim arrangements in place to address the risk of fire), they could not provide evidence to show that all members of staff had been trained in child safeguarding to the required level, they failed to ensure that necessary pre-employment checks had been completed on staff, and failed to ensure that staff had completed mandatory training. When we returned to the practice for the follow-up inspection in October and November 2016, we found that all of these issued had been addressed.

• At the time of the initial inspection the provider had not ensured the correct legal authorisations were in place for staff to carry out their roles safely, specifically, they had not put Patient Specific Directions in place to allow their healthcare assistant to administer medicines. These were in place when we returned to the practice in November 2016.

• Overall, staff assessed patients’ needs and delivered care in line with current evidence based guidance. When we initially inspected the practice we found that they did not have an effective system for recording and acting on medicines updates and safety alerts. We also found that  the practice had failed to ensure that a complete and contemporaneous record was kept in respect of each service user, they did not have care plans in place for all patients who needed them, and there was a lack of evidence that the outcome of assessments of capacity to consent were recorded in patient records. When we returned for the follow-up inspection we saw evidence that the practice was appropriately recording and acting on safety alerts and that care plans were in place. However, we found evidence that in some cases consultations were still not being adequately recorded. All of the examples we saw were the responsibility of one member of staff, and we were aware that issues relating to this individual’s performance were being addressed externally.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. The practice had recently trained two members of staff as repeat prescribing clerks and face to face training sessions had been provided to these members of staff by one of the GPs, that covered which medicines they were allowed to issue prescriptions for; however, written guidance was not in place.

• Data showed patient outcomes were below the local and national average in some areas; however, results from the Quality Outcomes Framework showed the practice’s performance had improved during the 2015/16 reporting year compared to the previous year, and the practice had introduced measures to further improve during the current reporting year.

• 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. At the time of the initial inspection we found that the provider had failed to ensure that every member of staff had received an appraisal. During our re-inspection on 1 November 2016 we found that appraisals had been completed for all staff.

There was one area where the provider must make improvement:

• They must put arrangements in place to ensure that all staff are making complete and contemporaneous records of patient consultations.

   

In addition, they should make improvements in the following areas:

• They should ensure that written guidance in put in place for the issuing of repeat prescriptions.

• They should ensure that they are regularly checking uncollected prescriptions and that arrangements are in place to contact vulnerable patients who have not collected their prescription.

• They should take further action to ensure that carers are identified and supported.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice