Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Cottage Surgery on 2 December 2016. The overall rating for the practice was requires improvement. The ratings for providing a caring and responsive service were good but the ratings for providing a safe service were inadequate and for providing an effective and well led service were requires improvement as we identified breaches in regulations. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for The Cottage Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 5 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 2 December 2016.

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

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

• A system called Doctor First had been developed and implemented by the GP partner. in order to improve patient access and on the day care. This resulted in the second lowest A and E attendance of the practices within their Clinical Commissioning Group.

• Patients said they found it easy to speak with and where appropriate have an appointment with a named GP and there was continuity of care, with urgent and non-urgent appointments available the same day.
• There was an open approach to safety and a system in place for reporting and recording significant events and dealing with safety alerts. However we found that alerts and events were not always recorded consistently.
• The practice had clearly defined systems to minimise risks to patient safety. However on the day of our inspection we found that vaccines and emergency medicines were not stored securely and the cold chain policy was not followed consistently.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.
• Results from the national GP patient survey were much higher than local and national averages and showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Patients spoke highly of the level of care they received and described staff as professional, supportive, sympathetic and always caring.

• Information about services and how to complain was available and easy to understand.

• There was a governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

The areas where the provider should make improvements are:

• Ensure the systems relating to significant events and safety alerts consistently record all events and alerts.

• Review arrangements to ensure patient confidentiality is maintained during consultations.

• Ensure the cold chain policy is followed consistently.

• Ensure treatment room is kept locked when not in use to give assurance that emergency medicines and vaccines are stored securely.

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 Cottage Surgery on 2 December 2016. Overall the practice is rated as requires improvement.

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

• The practice had a vision to provide a high quality service in a timely manner.,much of which they told us was being delivered via the successful implementation of Dr First. Although Dr First was contributing to the very positive access results in responsive care we found that the practice lacked the capacity to identify and implement some of the other required systems and processes to support that overall vision.

• Patients were at risk of harm because effective systems and processes were not in place to keep them safe. For example, patient safety alerts, infection control, emergency medicines, regular temperature monitoring of the refrigerators used to store vaccines.

• Risks to patients were assessed and well managed, with the exception of those relating to fire and legionella.

• The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse. However the system in place in place to monitor adults and children on the at risk register or identify looked after children was not consistent.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to speak with and where appropriate have an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• Patients were very positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice did not have a robust system in place to monitor the training of the GPs and staff within the practice. For example, not all clinical staff had received appropriate training in safeguarding to ensure they were up to date with current procedures.
• Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Comment cards were positive about the standard of care received. They identified that staff were caring, polite, respectful and professional.

• Information about services and how to complain was available and easy to understand.

• There was a limited governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

• Significant issues that threaten the delivery of safe and effective care had not been identified or adequately managed.

The areas where the provider must make improvements are:

• Ensure there is sufficient leadership capacity in the practice to generate a culture of improvement that ensures that systems and governance are in place to deliver safe and effective care.

• Improve the systems and processes in place for the management of risks to patients and others against inappropriate or unsafe care. For example, patient safety alerts, infection control, emergency medicines, regular temperature monitoring of the refrigerators used to store vaccines, fire and legionella.

• Ensure the system in place for palliative care monitoring is effective to ensure all relevant information is in place.
• Ensure clinical audits are undertaken in the practice which include completed clinical audit or quality improvement cycles to ensure improvements have been achieved.
• Ensure appraisals which are undertaken follow the practice policy.

The areas where the provider should make improvement are:

• Embed the reviewed process for significant events to ensure that recording and documentation is in line with the practice policy.

• Embed the system for safeguarding to ensure that coding and monitoring of vulnerable adults and children on the at risk register or looked after children to ensure it is consistent.

• Embed the system to ensure prescriptions stationery and sharps bins are dealt with in line with national guidance

• Review the training needs analysis and ensure a process is in place to ensure staff training is monitored and all staff are up to date with training appropriate to their role.

• Ensure verbal references are documented in line with national guidance. Review the current systems in place to ensure all clinicians are kept up to date with national guidance and guidelines embed the new process for clinical meeting minutes to include safety alerts and updates on NICE guidance.
• Ensure any verbal complaints are recorded as per the practice policy.
• Ensure policies and procedures are reviewed and include additional information such as name of responsible person, where clinical waste and oxygen is stored.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within 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