This practice is rated as Good overall. (Previous inspection 18 January 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Acorn & Gaumont House Surgery on 12 April 2018 this was to follow up on breaches of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified at our last inspection completed on 18 January 2017.

The concerns related to published data which showed that the practice was below local and national averages for health outcomes relating to diabetes, hypertension, and poor mental health. Outcomes for patients with learning disabilities were low. Published data also highlighted that patients rated the provider below local and national averages for consultations with GPs, and general satisfaction with the service. In response to our findings we issued a requirement notice for breaches of regulation 17.

At this inspection we found:

That the practice had made significant improvement in respect of clinical outcomes. Though the practice had gathered internal feedback which was positive and had taken action in response to the national patient survey after the last inspection; the most recent national patient survey still showed that the practice was rated below local and national averages in respect of some aspects of care provided.

• The practice did not have a clear protocol in place for the management of sepsis and some staff we spoke with were not able to outline the red flag warning signs of sepsis. However a protocol was put in place and displayed in clinical rooms and reception shortly after our inspection.
• The practice had clear systems to manage risk in most instances so that safety incidents were less likely to happen. On most occasions when incidents did happen, the practice learned from them and improved their processes. However action had not been taken in response to risks associated with legionella until after our inspection.
• Performance against clinical targets had shown significant improvement. Published data for 2016/17 showed improvement in all areas, though the practice were still not in line with local and national performance. However unverified data provided by the practice for 2017/18 showed that the practice were in line with national clinical performance in almost all areas.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided through clinical audit to ensure that care and treatment was delivered according to evidence- based guidelines. The practice was not routinely auditing individual consultations although we saw evidence of systems being developed to do this.
• National patient survey scores related to compassion, kindness, dignity and respect were below local and national averages. Although no action was taken by the practice in response to feedback regarding clinical staff the practice had completed their own internal survey which indicated that satisfaction had improved. Comment cards were mainly positive about the care received and patients we spoke with provided mixed feedback.
• Some patients found it difficult to access appointments and get through to the surgery on the telephone. The practice had taken action in response to this feedback and their own internal patient survey indicated improvement with patient satisfaction.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider Must make improvements 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:

• Implement a system to enable review of clinical consultations.
• Work to improve uptake of cervical screening in line with target set by Public Health England.
• Have oversight of risk management activities undertaken by third parties.
• Continue to review the appropriateness of emergency medicines held on site.

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 The Acorn & Gaumont House Surgery on 18 January 2017. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events; however, there was no effective system in place for ensuring that safety alerts from external organisations were actioned. Other risks had been assessed and managed well.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance; however, patient outcomes for health indicators related to diabetes, hypertension and poor mental health were below local and national averages. Outcomes for patients with learning disabilities were also low.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. We requested, but were not provided with, records of information governance and fire safety training for two members of staff; this training was completed shortly after our inspection.

• The majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment; however, the practice was rated below average for some aspects of consultations with GPs, the helpfulness of receptionists and their overall experience of the service.

• Patients said they had not always found it easy to make an appointment or reach the practice by telephone.
• 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, but two out of five complaints we reviewed had not been responded to in a timely manner.

• The practice had good facilities.

• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

• The provider had a number of policies in place but we identified instances where it had not followed its recruitment policy.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Assess, monitor and improve performance, patient outcomes, access, and patient satisfaction with the service, and implement an effective strategy to ensure the delivery of good quality care.

The areas where the provider should make improvement are:

• Implement an effective system to ensure that safety alerts are actioned.

• Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

• Monitor and review changes made in response to patient feedback, specifically to improve waiting times and access to care for patients.

• Implement recruitment arrangements that include all necessary employment checks, and maintain on-going training for all staff (including the maintenance of relevant records) in order to protect patients from any associated risks to their health and welfare.

• Respond to complaints in a timely manner.

• Conduct regular performance reviews for all staff, and follow practice policies.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice