Letter from the Chief Inspector of General Practice

We previously carried out a comprehensive inspection at Swanpool Medical Centre on the 9 June 2015. The practice received an overall rating of requires improvement. We carried out a follow up comprehensive inspection on the 16 November 2016 to see if improvements had been made. The practice continued to be rated requires improvement overall with an inadequate rating for services being well led. The practice was issued with a warning notice in relation to regulation 17 good governance. The full comprehensive reports for both these inspections can be found by selecting the ‘all reports’ link for Swanpool Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken to follow up progress made by the practice since the inspection on 16 November 2017 and was an announced comprehensive inspection on 13 July 2017. Although we have seen improvements the practice continues to be rated as requires improvement overall.

Our key findings were as follows:

• We found that significant improvements had been made to address concerns raised during our previous inspection. The practice was reliant on the use of locum GP and there had previously been little evidence of involvement of these GPs within the practice’s clinical governance arrangements including the sharing of best practice, management of incidents, safety alerts, complaints and learning from these.
• At this inspection we found effective systems and regular clinical meetings had been put in place for disseminating and information sharing among all staff including locum GPs.
• There had been improvements to the systems for reporting and recording significant events and to ensure learning from these. Staff were aware of their responsibilities.
• Risks to patients were assessed and managed, we saw improvements in relation to infection control, the management of prescriptions, emergency medicines and equipment.
• The practice was reliant on long term locum GPs to deliver the service. However, there were no contracts in place to clarify working arrangement or commitments.
• There were improvements in the way in which best practice was shared and discussed among clinical staff to support the delivery of care.
• Staff had been trained to provide them with the sills, knowledge and experience to deliver effective care and treatment.
• Data showed the practice performed well in terms of patient outcomes overall. However, we identified palliative care as an area for improvement and to ensure patients received timely prescriptions.
• Patient feedback received on the service was mixed. Data from the national GP patient survey was lower than local and national averages across most questions. Improvement was limited and in many areas was lower than the previous patient survey. Feedback from the CQC comment cards was positive overall.
• Information about how to complain was available and easy to understand. Learning from complaints was shared.
• The practice had good facilities and was equipped to treat patients and meet their needs. We saw that there had been some refurbishment of the premises since our previous inspection and better organised.
• We saw improvements in the governance arrangements since our previous inspection. Policies and procedures were being reviewed and made practice specific. However, we were not fully assured that there was sufficient capacity to manage patient information received for timely action.
• However, there were also areas of practice where the provider needs to make improvements.

In addition the provider should:

• Consider adding alerts to patients, where appropriate who have direct links to a patient known to be at risk of harm.
• Ensure appropriate sharps bins in place that reflect the needs of the practice.
• Ensure appropriate coding of patients on high risk medicines so that they can be easily identified.
• Ensure contingency arrangements for clinical cover are in place.
• Maintain formal supervision records of support provided for the Advanced Nurse Practitioner.
• Develop care plans to support patients in the management of their long term health conditions.
• Continue to review patient feedback, including feedback from the national patient survey and identify how the service might be further improved.

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 Swanpool Medical Centre on 16 November 2016. The practice had previously been inspected in June 2015 and was found to be in breach of regulation 16 (complaints), regulation 17 (good governance) and regulation 19 (fit and proper persons employed). The practice was rated as requires improvement overall.

Following the previous inspection the practice sent us an action plan detailing the action they were going to take to improve. We returned to the practice to consider whether improvements had been made. We found the practice had made insufficient improvements to improve the service.

The breaches in relation to regulation 16 (complaints), regulation 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been addressed and the practice was now compliant with these regulations. However, the breaches in relation to regulation 17 (good governance) had not been fully met. We also identified additional breaches in relation to regulation 12 (Safe care and treatment).

The practice is rated as requires improvement.

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

• The systems for reporting and recording significant events had not improved sufficiently since our previous inspection to support and improve safety in the practice. There was little evidence to show that clinical staff were involved in reporting and sharing incidents and their learning.
• There had been some improvements in the management of risks since our previous inspection for example, those relating to staff recruitment and fire safety. However we found weaknesses in relation to infection control, prescription safety and the follow up of actions required from the legionella risk assessment.
• Data showed patient outcomes were comparable to local and national averages in most areas.
• There was little evidence that clinical audit was driving quality improvement in patient outcomes.
• Staff had the skills, knowledge and experience to deliver care and treatment.
• There was evidence of staff appraisals but these had not all been appropriately completed.
• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs however feedback received from community teams identified areas for improvement.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
• We saw improvements in the management of complaints since our previous inspection. Information about services and how to complain was available and easy to understand and learning from complaints was shared at practice meetings.
• Patients said they did not always find it easy to make an appointment. Changes had been made to the appointment systems which had led to improvements such as a reduction in the number of non attendances and increased use of the on-line booking system.
• The practice was accessible to patients and equipped to treat patients and meet their needs.
• Governance arrangements were not sufficiently effective to ensure all staff groups were involved in supporting the service to improve.

The areas where the provider must make improvement are:

• The practice must improve governance arrangements for managing quality and safety.
• Ensure effective systems are in place for all staff (including clinical staff) to be involved in reporting and learning from incidents and complaints; for discussing and sharing best practice guidance and clinical audit
• Ensure safety alerts are consistently acted upon and for monitoring and acting on recommendations arising from risk assessments.
• Review and implement effective practice specific policies and share with staff.
• Ensure effective systems are in place for managing uncollected patient prescriptions.
• Ensure effective systems for managing prescription stationery.
• Ensure effective systems are in place for managing infection control within the practice.

The areas where the provider should make improvement are:

• Check that the thermometer on the medicines fridge is operating correctly to ensure that vaccinations are stored in line with public health guidlines.
• Review systems for managing equipment and medicines used in a medical emergency to ensure they can be accessed quickly with clear monitoring processes.
• Review the effectiveness of staff appraisals to ensure staff have the opportunity to discuss any learning and development needs.
• Review and develop effective multi-disciplinary working arrangements with the community teams.
• Ensure patients with a learning disability receive the opportunity for an annual health review.
• Continue to review patient feedback including feedback from the national patient survey and identify how the service might be improved.
• Review and implement policies that are practice specific and support staff in the day to day running of the practice.
• Review staff understanding and application of relevant consent and decision-making requirements for those who may lack capacity and children including the Mental Capacity Act 2005

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than 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 Swanpool Medical Centre on 9 June 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective, responsive and well led services and good for providing a caring service. It also required improvement for providing services for the six population groups (older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). This is because the concerns that have led to the overall provider rating apply to everyone using the practice, including these population groups.

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

• At the time of the inspection Swanpool Medical Practice was in a transitional phase following a recent merger of two former practices. The practice was reliant on locum GPs to provide the clinical services at the practice. The principal GP also ran three practices and was a salaried GP at a fourth practice. Within this context the main challenge has been to develop robust governance arrangements.
• The provider had not correctly registered the practice with the Care Quality Commission. The practice was registered as a sole provider but at the inspection told us that the practice was a partnership.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded but did not always demonstrate clear learning which was shared among staff.
• Risks to patients were assessed and managed, but assessments were not always robust including those relating to fire and staffing.
• There was a lack of current published national data relating to patient outcomes due to the merger of the two former practices at Swanpool Medical Centre in June 2014 but early indications from practice data appeared to be showing good progress.
• Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Patient feedback about the service was mixed. Satisfaction with the service and quality of consultations was generally in line with the Clinical Commissioning Group (CCG) average but below the national average.
• Information about services and how to complain was available but the practice did not operate a robust complaints system to ensure complaints were appropriately managed.
• Patients had reported access to appointments was difficult and the practice had responded to this through increased sessions.
• Governance arrangements were not robust to ensure important issues affecting the practice were routinely discussed with staff.
• The practice had sought feedback from patients.

The areas where the provider must make improvements are:

• Ensure robust governance arrangements are in place for the management of quality and safety. Including systems to ensure important information is routinely discussed and shared with staff and actions identified implemented to improve the service provided. This would include management of significant events, complaints, safety alerts, audits, best practice guidance and the management of risks relating to fire safety and staffing.
• Ensure appropriate recruitment information is maintained for staff employed.
• Ensure audits undertaken are full audit cycles to demonstrate improvements made and that the findings are shared to deliver those improvements.
• Ensure a robust complaints process is in place which is consistently followed.

In addition the provider should:

• Ensure systems are in place for maintaining an accurate audit trail for prescriptions.
• Review arrangements to ensure patient dignity is not compromised in using grilles at reception.
• Ensure staff are aware of systems for sharing information with the out-of-hours provider.
• Ensure staff have an awareness of the Mental Capacity Act (2005) and how it applies to their role.
• Maintain robust systems for checking and recording checks of emergency equipment to provide assurance that they have been done and the equipment is fit for use.
• Develop systems for maintaining staff training records so that the practice can be assured that training relevant to staff roles have been completed and any identified development needs met.
• Ensure policies and procedures are understood by staff and embedded within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice