We carried out an announced comprehensive inspection at The Barham & Claydon Surgery on 10 December 2018.

The practice was inspected in July 2017 and rated as requires improvement overall, with inadequate for providing safe services, requires improvement for providing effective and well led services, and good for providing caring and responsive services. A further inspection was undertaken on 11 April 2018 to follow up on the breaches of regulation identified at the July 2017 inspection. The practice was rated requires improvement overall, with requires improvement for providing safe and well led services and good for providing effective, caring and responsive services. The full comprehensive reports on the July 2017 and April 2018 inspection can be found by selecting the ‘all reports’ link for The Barham & Claydon Surgery on our website at www.cqc.org.uk.

At this inspection we followed up on breaches of regulation identified at the previous inspection in April 2018.

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.

We have rated this practice as good overall and good for all population groups.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Improvements made since our previous inspection had been embedded.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• Staff felt supported and there was a focus on continuous learning and improvement at all levels of the practice.

The areas where the provider should make improvements are:

• Improve the documentation relating to children who fail to attend hospital appointments.
• Formalise the ongoing checks of the professional registration of staff.
• Continue to work to improve the number of carers identified.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

This practice is rated as Requires Improvement overall. At the previous inspection in July 2017 the practice were rated as requires improvement overall; they were rated as inadequate for providing safe services, requires improvement for effective and well-led services and good for caring and responsive services.

We carried out an announced comprehensive inspection at The Barham & Claydon Surgery on 11 April 2018 to follow up on breaches of regulations.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

At this inspection we found:

• The practice had made improvements following our previous inspection. They had improved the systems and processes to meet the required standards of infection prevention and control, they had ensured all staff had completed their basic life support training and had updated their business continuity plan to reflect a wider variety of risk.
• The practice had implemented and monitored a process to share relevant and current evidence based guidance and standards with staff, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
• The practice had some systems to manage risk so that safety incidents were less likely to happen. However the practice had not improved the system and process in the dispensary to ensure near miss records contained sufficient detail to fully investigate identified lessons or trends and share learning to make improvements. We found a lack of evidence to show the practice monitored and improved quality in relation to the dispensary. For example, the practice did not undertake any regular audits, survey questions or regular assessment that dispensary staff were competent to undertake their role. Following the previous inspection the practice had undertaken training for the storage, recording and handling of controlled drugs. The practice had also joined the Dispensing Doctors Association.

• The practice did not always record the learning points from all significant events and the actions taken were not always clearly documented to ensure learning was shared with all the staff.
• Staff we spoke with demonstrated they were knowledgeable about their own roles and responsibilities. However we found there was not a cohesive approach from the management team to ensure they had complete oversight of their staffs roles and performance.
• The practice had systems and processes in place for safeguarding to ensure that patients were safe from harm or abuse. We noted the policy did not contain practice specific information to ensure staff had easy access to escalation routes; although there was some escalation information displayed in all clinical rooms. Staff were told to inform the duty doctor of any concerns. On the day of the inspection we were told the safeguarding lead was on maternity leave and we found that staff were unclear on who was covering this role.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice’s performance in relation to the Quality Outcome Framework (QOF) results were 96%. This was in line with Clinical Commissioning Group (CCG) and national averages.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Patients were positive about the practice and in particular, the staff team.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• Establish and operate 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:

• Review and improve the information provided to patients to ensure they are notified of the methods to escalate their complaint if they are dissatisfied with the response.
• Review and improve the uptake of learning disability health checks.
• Continue to work to improve the number of carers identified and supported.
• Review and improve documentation relating to children who fail to attend hospital appointments.

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 Barham and Claydon Medical Practice on 26 July 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 for reporting and recording significant events.
• The practice did not have good facilities and although it was equipped to treat patients and meet their needs, there was a need for improvement.
• Risks to patients were assessed but were not consistently or effectively managed. The practice needed to improve the processes for controlled drugs in the dispensary and a wide variety of premises-related concerns were contributory to poor maintenance of infection prevention and control processes.
• The practice did not have effective systems in place to keep all clinical staff up to date, instead clinicians maintained their own access to guidelines from NICE and used this information to deliver care and treatment that met patients’ needs. When we reviewed records and spoke with clinicians we noticed this took place but was not supported by an effective system in the practice.
• Clinical audits demonstrated quality improvement, but they did not always reflect up to date, evidence based guidance.
• The practice’s use of the computer system required improvement to provide improved assurance around patient recall systems; we noted health reviews for patients with long term conditions were not always recorded appropriately.
• 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.
• Data from the National GP Patient Survey published in July 2017 showed patients rated the practice above average for most aspects of care.
• 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. Staff told us they were able to undertake development opportunities but records indicated some elements of training overdue for a small number of staff.
• Various meetings took place in the different teams in the practice and with external services. However, internal clinical meetings were not held consistently nor had they been recorded since January 2017. The practice manager explained that they had already implemented a new schedule of clinical meetings, commencing in August 2017, with a standard agenda, including recurring items such as significant events.
• The provider was aware of and complied with the requirements of the duty of candour.

The area where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure all premises and equipment used by the service provider are fit for use.

The areas where the provider should make improvement are:

• Within the dispensary, the practice should implement clear guidance for the compilation of monitored dosage systems and effective recording of near miss incidents and expiry date checks.
• Implement a process to provide timely (refresher) training, including training in basic life support, safeguarding and undertaking legionella testing.
• The business continuity plan should consider a broader scope of risks.
• Implement effective processes to ensure all clinical staff are up to date with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. The current audit programme should also be reviewed to take into account current evidence based guidance.
• Maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.
• Review the system for the recording of minutes of clinical meetings to ensure they contain information on decision making processes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice