This practice is rated as Good overall. (Previous inspection October 2016 – Good with safe domain rated as requires improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Billesdon surgery on 26th April 2018 following up on previous breaches of regulations found in 2016.

In October 2016 the practice was issued with a requirement notice for the breach of regulation 12 for Safe care and treatment of the Health and Social care act. The regulation was not being met as the registered person did not do all that was reasonably practicable to assess, monitor, manage and mitigate risks to health and safety of service users. The practice needed to make improvements in systems to manage medications and review the repeat prescribing procedure for high risk medications.

At this inspection we found:

The practice had addressed all concerns that were identified at the previous inspection.

• The practice had clear systems to manage risk so that safety incidents were less likely to happen.
• 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.
• There was an emphasis on continuous learning and improvement at all levels of the practice. This included the significant event analysis, sharing and updating of policies, clinical audit and feedback from patients and staff.
• The practice implemented and monitored changes to ensure the patients’ needs were always met.
• 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.
• There were named accountable clinicians for areas of the practice and also non-clinical lead for patients with dementia or carers.
• The leadership structure was well embedded within the practice.

The areas where the provider should make improvements are:

• Review the process to ensure all safety alerts are received, recorded and acted upon.
• Review any missed appointments for children or vulnerable adults within secondary care documenting the response in all cases and act upon if required.

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 The Billesdon Surgery on 19 July 2016. The purpose of this inspection was to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings at our inspection in September 2015 when we found the practice to be inadequate overall. Overall the practice is now rated as good.

At this most recent inspection we found that extensive improvements had been made and specifically, the ratings for providing an effective and well led service had improved from inadequate to good and the rating for providing a safe service had improved from inadequate to requires imiprovement. The rating for providing a responsive service had improved from requiring improvement to good and the rating for providing a caring service remained good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Overall, risks to patients were assessed and well managed with the exception of the repeat prescribing process. Action was taken on the day of our inspection to rectify the issue identified in this area.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• 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 sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

Ensure effective systems and processes are in place relating to medicines management, including dispensary SOPs containing all necessary information, secondary thermometers for the medicine refrigerators being set in line with the practice policy, the protocol for methotrexate prescribing being followed and the changes to the repeat prescribing process embedded and followed.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 Billesdon Surgery on 17 September 2015. Overall the practice is rated as inadequate.

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

• The system for reporting, investigation and dissemination of learning from significant events was inconsistent and disjointed so safety was not always improved.
• Data showed patient outcomes were in line with the national average. Although some audits had been started, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• Systems and processes within the dispensary were not robust.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day due to the practice’s daily open surgery.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• We found there were limited means of accessing information about how to complain.

• The practice had a number of policies and procedures to govern activity, but some were over five years old and there was no evidence they had been reviewed since.

• The practice had limited means of encouraging feedback from patients with a view to engaging patients in the delivery of the service and had not always acted on issues raised by staff.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, the system in place for monitoring and reviewing patients on methotrexate was not adequate.

The areas where the provider must make improvements are:

• Ensure there is a clear and consistent system for dealing with significant events and that staff are supported to raise incidents.

• Ensure the complaints system is accessible.

• Ensure there are formal governance arrangements in place and staff are aware how these operate, including having appropriate policies and guidance in place.
• Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.

• Ensure there are effective systems in place for monitoring patients and the quality of care, including appropriate care plans being in place, the ‘hypertension improvement plan’and ‘methotrexate prescribing protocol’ being implemented and adhered to and robust clinical audits being undertaken in the practice, including completed clinical audit or quality improvement cycles.

• Ensure all staff are up to date with mandatory training.

• Ensure appropriate fire safety arrangements in place, including regular fire drills and fire alarm testing and an up to date fire risk assessment in place.

• Ensure there is a robust system in place for the management of emergency equipment and medicines.

• Ensure all staff receive annual appraisals.
• Ensure systems and processes in the dispensary are robust, including adequate leadership and that competencies of dispensary staff are checked appropriately.
• Ensure appropriate risk assessments are in place, for example,legionella and staff working alone at branch surgery.
• Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, including actions from infection control audits being recorded and implemented.
• Ensure a statement of purpose is in place and submitted to the Care Quality Commision.

In addition the provider should:

• Ensure a comprehensive business continuity plan is in place.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have not 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. I have also served a notice on the provider placing conditions on their registration, which they must comply with.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We spoke with five patients who used the service. They were all very positive about their experiences. One person said “The drop in surgery is fantastic” and “It’s a great service, they are 110%.” Patients also said the reception staff were “always polite and helpful” and they were normally seen on time. One patient told us they didn’t mind waiting when they turned up for the drop in surgery, as they knew they would be seen that day. Other patients told us they could normally get an appointment within 48 hours.

We saw staff had attended infection control training, particularly around hand washing techniques and this was supported by the training records we saw on the day. We also saw that all areas of the practice were clean and organised. We saw patients and staff had good access to hand washing facilities and to antibacterial gels. Patients told us staff wore protective equipment when appropriate and the treatment rooms were clean.

We saw that medication was stored in locked cupboards in the dispensary at the Billesdon surgery. Emergency medication and equipment was available in both surgeries, and records supported the medication was in date.

We saw the appropriate checks were undertaken before staff began work.

Patients told us they were aware of the complaints procedure and could to items on the waiting room notice boards. Generally people told us they had nothing to complain about.