Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Steeple Bumpstead Surgery on 27 July 2017. 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 a system in place for reporting and recording significant events.

• The practice had clearly defined and embedded systems to minimise risks to patient safety. The practice had an effective system in place to manage the MHRA and patient safery alerts they received. We saw evidence of searches in relation to the alerts and documented actions taken. However, on the day of the inspection the practice were not signed up to receive MHRA updates. Following the inspection the practice had rectified this and had also completed searches on all the updates relating to primary care from 2016/17 and 2017/18.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

• Patients we spoke with said they found it easy to make an appointment 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 staffing structure at the administrative level and staff were aware of their own roles and responsibilities. However, it was unclear who was the clinical lead at the practice. Staff we spoke with said one of the GPs whilst that GP said that they were not the clinical lead, although would give advice and support if required.

• The practice proactively sought feedback from staff and patients, which it acted on.

• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

• Risks to staff and patients had been assessed and managed appropriately. Staff had received training that was specific to their roles and the practice manager had records that showed the training completed and when it was due for renewal.

• Appropriate checks were carried out as to the fitness of staff to practice and all staff had current and effective registrations with their professional body. All relevant staff had received a disclosure and barring service check prior to employment.

• Staff carrying out chaperone duties had received training and a disclosure and barring service check was in place.

• There was sufficient and appropriate equipment for use in the treatment of patients, including in the event of a medical emergency and the equipment was calibrated to ensure it was working correctly.

• There was a comprehensive business continuity plan in place in the event of an emergency taking place that disrupted the services to patients.

• There was a programme of clinical audit that demonstrated quality improvement.

• Practice policies and procedures had been reviewed to ensure that they were up to date and practice specific.

• Carers were identified, although on the day of inspection the coding was not correct and the system showed two carers. Information supplied following the inspection showed the practice had identified 1.9% of the practice list as carers.

• The practice had an effective patient participation group and meetings showed how the practice had listened and responded to patient feedback.

  The practice had actively improved the care and experience for patients with dementia. They had signage that was dementia friendly and had produced a video with a patient and their carer that would be used for training throughout the organisation to improve care for patients and carers.

• Information about how to complain was available and evidence from three examples reviewed showed the practice responded quickly to issues raised. We viewed practice minutes and saw that complaints were discussed. However there were no documented lessons learned.

Actions the practice SHOULD take to improve:

• Ensure the process for safety alert update is embedded.

• Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.

• Continue to improve to manage and monitor processes to improve outcomes for patients.

• Review the process for sharing and documenting lessons learned and actions taken from incidents and complaints.

• Review the regulated activities to ensure the practice is registered for the regulated activity of maternity and midwifery if applicable.

• Consider how best to support patients who are hard of hearing.

• The practice should ensure that all emergency medicines are readily available for use and embed the process for checking of emergency medicines and equipment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Steeple Bumpstead Surgery on 26 February 2019. We carried out inspections at the provider’s head office with colleagues from the Hospitals directorate on 24 January 2019 and 5 March 2019.

We previously carried out an inspection at Steeple Bumpstead Surgery on 27 July 2017. At that inspection, we rated the practice as good overall, with requires improvement for providing safe services. We did not identify any breaches of regulation at that time, but we identified where the practice should improve, for example by reviewing the regulated activities for which it was registered and improving outcomes for patients.

This inspection was to follow up on areas where we said the practice required improvement as identified in our inspection of 27 July 2017 as well as to provide new ratings.

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.

This practice is now rated as inadequate overall.

We rated the practice as inadequate for safe because:

• Checks of equipment and premises were not reliable.
• There was a reliance on clinical locum staff but not a consistent and safe approach to managing absences of these clinicians.
• There had not been a multi-disciplinary meeting involving other healthcare professionals since September 2018, despite this being identified as a required action following concerns raised at the end of 2018.
• Prescription stationery and medicines were not held securely.
• There were no systems for clinical support and supervision of staff. There were no documents to define the prescribing remit of the advanced nurse practitioner.

We rated the practice as inadequate for effective because:

• Performance was below average in respect of diabetes, asthma, COPD, cancer and mental health. Identified improvements had not been made following our 2017 inspection.
• Information about patients was not shared with other healthcare professionals at a regular meeting with a view to ensuring continuity of care.
• Information cascades were not effective.
• There was a lack of quality improvement processes in place for example, there had been no clinical audits completed in the last two years.
• The learning and development needs of clinical locum staff were not assessed.

We rated the practice as requires improvement for responsive because:

• Feedback in the GP patient survey was in line with or better than averages in relation to access; however, some patients raised concern about accessing appointments.
• There had been occasions where appointments had to be cancelled by the practice at short notice due to a lack of clinicians.

We rated the practice as inadequate for well-led because:

• The provider was unaware of some challenges to safety and effectiveness at the practice.
• The provider’s vision had not been effectively incorporated into the day to day running of the practice.
• There was limited effective oversight.
• Patients and others were not confident that concerns would be responded to.

We rated the practice as good for caring because:

• Feedback in relation to the care and treatment provided was positive. Patients had trust and confidence in the clinical staff.

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

• 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:

• Improve processes for ensuring medical equipment is suitable for use for example, to ensure anaphylaxis packs have a tamper evident seal on them.
• Define and make staff and patients aware of the clinical remit of the advanced nurse practitioner.
• Review the space and environment of the dispensary. Ensure staff are aware of who has overall responsibility of the dispensary.
• Consider mechanisms for obtaining patient feedback such as implementation of an in-house patient survey.
• Review the protocol to offer support to patients affected by bereavement.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care