We carried out an announced comprehensive inspection at The Birches Medical Practice on 11 December 2018 as part of our inspection programme. The practice was previously inspected in September 2015 and rated as good.

Our judgement of the quality of care at this service is based 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 requires improvement overall.

This means that:

• People were protected from avoidable harm and abuse, however some of these systems and processes needed to be improved and embedded into the culture of the practice.
• The provider had a detailed action plan in place to address shortfalls within the practice, such as upskilling staff to address issues with recruiting GPs.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and drive care. For example, the practice had a system to monitor patients on a range of medicines, including high risk medicines.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met by the way in which services were organised and delivered. For example, the practice had introduced a new appointment system to ensure patients were seen by the appropriate clinician.
• The leadership and culture of the practice promoted the delivery of high quality person-centred care.
• The practice encouraged continuous improvement and innovation. For example, they were supporting new members to the management team.
• Staff reported they were happy to work in the practice and proud of the changes that had been made.

We rated the practice as requires improvement for providing safe services because:

• The practice had not previously undertaken risk assessments in relation to, health and safety and legionella’s disease. Just prior to our inspection the practice engaged external companies to undertake these assessments. The assessments identified actions for the practice to undertake such as water temperature testing. The practice had started to build the action plan and implement and embed systems and processes to ensure patients and staff were kept safe.
• The practice had not previously undertaken an infection prevention and control (IPC) audit. The IPC lead and management team had undertaken one prior to our inspection, however, this was not sufficiently detailed to ensure all areas would be reviewed and recorded. The practice immediately contacted the IPC team at the CCG who agreed to visit the practice and undertake a full review of the practice system and process and training needs.
• The practice did not hold a Control of Substances Hazardous to Health (COSHH) register and were not fully aware of the requirements. The practice immediately contacted an external company for a copy of the register held by them and added all other substances that may be used in the practice.
• Prescription stationary was stored in a locked cupboard; however, they did not monitor their use.
• The practice did not have full oversight of all safety alerts, on the day of inspection we found that the practice had not acted on all alerts.

We rated the practice as requires improvement for providing responsive services because:

• Data from the 2018 GP patient Survey showed patients satisfaction regarding access to the practice was statistically comparable; however, most indicators were below the CCG and national averages. Some comments on NHS choices and on the comment cards we received reported negative experiences.

We found the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found the provider should:

• Review the system for recording carers to ensure they are offered support.
• Maintain clear oversight of practice training records to ensure all staff are appropriately trained and updated.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We inspected this practice on 04 March 2015 as part of our new comprehensive inspection programme.

The Birches Medical Centre is located in a purpose built building and serves a population of approximately 8100 patients.

The overall rating for this practice is good. We found the practice was good in the safe, caring and well led domains as well as in the effective and responsive domains. We found the practice provided good care to older patients, patients in vulnerable circumstances, families, children and young patients, working age patients, patients experiencing poor mental health and outstanding care to patients with long term conditions.

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

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice was aware of its patient population and tailored its services accordingly.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a vision and strategy for the delivery of high quality care and staff were working towards it.
• 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.

We saw three areas of outstanding practice:

• The practice provided specialist nursing in MacMillan Cancer Survivorship care to patients suffering with cancer. This care focusses on patients living with or beyond cancer.
• The practice provided specialist diabetic nursing which allowed the practice to provide diabetic patients with a care provision normally encountered in secondary care. The practice had the ability to initiate insulin treatment and provide support through the initial process related to this intervention.
• The practice provided regular information evenings where different external speakers would educate patients on specialist health related topics.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

• Undertake a fire safety risk assessment and ensure staff are trained in fire evacuation procedures.
• Identify those staff required to be vaccinated against Hepatitis B and risk assess the roles where it is not required.
• Ensure all staff receive performance appraisals.

• Review the appointment system in light of patient feedback so that it meets their needs

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We conducted this inspection to follow up on the compliance action made at our last inspection on 05 February 2014, when we found that training deemed mandatory by the provider had not been completed by approximately three quarters of the staff at the surgery. This included training in health and safety, fire safety, infection control, safeguarding adults and children, and equality and diversity for clinical and non-clinical staff. In addition there was no evidence that the provider had an effective staff appraisal process in place.

During our inspection on 23 June 2014 we found that improvements had been made. We looked at the record of staff training and saw evidence that the majority of staff had completed training deemed mandatory by the provider.

We were told by the practice manager that the majority of staff had received an appraisal. We spoke with three members of staff who confirmed they had received an appraisal. We saw that there was an effective appraisal process in place. One member of staff told us, “I had an appraisal and they have listened and acted.”

We were assured by the provider that the mandatory training which remained outstanding would be completed, within two weeks of the date of this inspection. We were also assured by the provider that the appraisals for the minority of staff who had not yet received an appraisal would be addressed as soon as possible. Evidence was provided within two weeks of the inspection which demonstrated that the outstanding mandatory training and appraisals had been completed.

We spoke with six people who used the surgery. All of whom said that their privacy and dignity was maintained during their consultation.

We found that people were involved in decisions regarding their care and treatment. One clinician told us, “Patient partnership is crucial.”

We looked at the records of three people and saw their needs had been assessed and care and treatment was planned and reviewed. One person told us, “The clinical care here is excellent. If you are poorly, you can’t fault the care.” There was evidence that people’s care and treatment was reviewed. One person said, “I am reviewed regularly, about every six months. It is very thorough.”

We spoke with two newer members of staff, both of whom told us they had received an induction. We found this had not been documented. We noted that not all staff had completed mandatory training and that there was not an effective appraisal process in place.

We saw that the surgery had responded to comments that people had made in relation to issues regarding appointments. One person told us, “There was difficulty getting an appointment and that has improved. With the new practice manager, I see a lot of positive change already.”

There were effective systems in place to identify, assess and manage risks to the health, safety and welfare of people and others. These included learning from significant events, audits of clinical care and cleaning, and maintenance of fire equipment and the building.