Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Gate Surgery on 28 September 2016. The overall rating for the practice was good but with requires improvement for safety. The full comprehensive report for the 28 September 2016 inspection can be found by selecting the ‘all reports’ link for The Gate Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 March 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 28 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Outstanding.

There are a number of outstanding areas highlighted in our inspection report 28 September 2016. We found at both our inspections all the staff were passionate about the service and were proactive in seeking ways to assist patients and the local community. It was clear the staff worked hard to provide a good quality and equitable service in order to improve care and the quality of life for some of Rotherham’s most marginalised and vulnerable groups. Whilst provision of services to the patient group was potentially very challenging the staff enjoyed their work and felt supported in their roles and this was testament to the energy and enthusiasm for the service shown by the Registered Manager.

At this inspection we found the management team had reviewed their last inspection report in detail and had responded to all shortfalls identified not only to meet legal requirements but they had also responded to all minor points in the report. They had taken immediate action following the last inspection to improve and had continued to review and improve policies and procedures and systems where necessary.

Our key findings at this inspection were as follows:

The provider had made the following improvements to meet legal requirements:

• Systems to manage blank prescriptions had been improved to ensure these met NHS Protect guidance.
• Storage arrangements for vaccines had been improved to ensure these met Public Health England guidance. Arrangements for monitoring the temperature of vaccines when they were transported from the surgery had also been reviewed and improved.

The provider had also made the following improvements:

• A programme of refurbishment had been completed at Rosehill Medical Centre to improve infection prevention and control.
• Security arrangements had been reviewed and improved at the branch surgeries to control access
• Information had been included in complaint response letters to patients on how to escalate a complaint if they are not satisfied with the response from the practice. The practice policy and procedure and web site had also been updated with this information.
• The chaperone policy had been reviewed and updated with more guidance for staff.
• A member of reception staff had been employed to provide additional cover at branch surgeries.

The practice had continued to find innovative ways of working to improve care for their patients and at this inspection we found additional areas of outstanding practice:

• The practice had completed an audit prior to the last inspection to look at patients who had a confirmed diagnosis of human immunodeficiency virus (HIV) and if they had been offered the vaccinations as per the British HIV Association Guidance. In response to the initial audit they had implemented processes to improve the uptake of vaccinations and had invited all patients with the diagnosis to attend. A second audit since the last inspection showed an  increase in the number of patients who were offered vaccinations and uptake of the vaccinations. For example, HIV positive patients being offered outstanding vaccinations had increased from 0% to 100% and the uptake of HPV vaccination (for patients under the age of 26 years) had increased from 5% to 50%.
• Due to their specific patient population needs the practice offered screening and vaccination over and above the programme offered to new-born babies of parents diagnosed with Hepatitis B. All children of parents with this diagnosis, regardless of their age, were offered screening and vaccination at this practice. The practice had identified and offered screening for 57 children in this category, of these 37 had accepted screening. Even if parents declined screening for their child vaccinations were always offered. Of the 57 eligible children a potential total of 285 vaccinations can be given (based on a programme of up to 5 vaccines which not all children would need). The practice had given 207 vaccinations to this cohort with some children still requiring further scheduled vaccinations.

Additionally since the last inspection the practice had also taken the following actions to improve patient care:

• The practice had developed an in-house dementia team following a reduction in the service previously provided externally. The team included clinical and administration staff who had received specific training for this role. The practice had audited their records to identify patients who may be at risk of developing or were living with dementia. The practice had reviewed the care provided and was in the process of working with the patients and their carers to ensure the patients received the required assessments, treatment and support. They had developed systems to ensure on-going monitoring and regular review of their care.

• At the last inspection we did not identify any concerns about how the appointment system was managed although there were varied levels of patient satisfaction. However, we found the practice had been working to improve patient experience in relation to access to appointments in response to patient survey outcomes. Since the last inspection the practice had commenced the Productive General Practice programme. (Productive General Practice is a new programme from the NHS Institute which aims to support general practices in realising internal efficiencies, while maintaining quality of care and releasing time to spend on more value added activities.) The practice had used this system to further review their appointment system. Following an audit they had commenced a nurse practitioner triage system. This had been further audited and showed significant savings equating to 56 GP appointments. The practice had also increased the number of appointments available by 100 per week across the three sites. The practice was continuing to monitor patient satisfaction with the system.

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 Gate Surgery on 28 September 2016. Overall the practice is rated as good.

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.

• Systems were in place to safeguard patients whose circumstances made them vulnerable and the systems had been develop to minimise the risks related to their specific patient group.

• Risks to patients were assessed and generally well managed although improvements were required in areas relating to the management of blank prescriptions and the storage of vaccines.

• 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.
• The practice used innovative and proactive methods to improve patient outcomes. The practice worked closely with other organisations and the local community in planning how services were provided to ensure they met patients’ needs
• 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 although information about escalating complaints needed adding to the policy and procedure and response letters. Improvements were made to the quality of care as a result of complaints and concerns.
• Although the practice had a flexible appointment system, which had been developed to meet their specific patient demands, some patients said they did not find easy to make an appointment. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had strong and visible clinical and managerial leadership and governance arrangements. 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.
• The provider was aware of and complied with the requirements of the duty of candour.

• All the staff were very passionate about the service and were proactive in seeking ways to assist the patients and the local community. It was clear the staff worked hard to provide a good quality and equitable service in order to improve care and the quality of life for some of Rotherham’s most marginalised and vulnerable groups. Whilst provision of services to the patient group was potentially very challenging the staff enjoyed their work and felt supported in their roles and this was testament to the energy and enthusiasm for the service shown by the Registered Manager.

We saw areas of outstanding practice:

The practice population included a high percentage of patients from vulnerable groups such as asylum seekers, homeless patients and travellers. This offered the practice a number of challenges to

in the management of health care needs which included, high patient turnover, chaotic lifestyles, poor engagement and a lack of medical history. To minimise the risk posed by these challenges the practice used every opportunity to provide care and safeguard these patients often having to being flexible and opportunistic in their approach. They also supported the patients in a variety of ways to try to minimise the impact of their circumstances on their health. For example;

• The systems to safeguard patients had been developed to meet the specific risks of the patient population. This included closely monitoring children on the child protection register at specific intervals, depending on their age. For example, children up to two years of age were monitored three monthly and if they had not seen a clinician in that time they were referred to the health visitor. The practice had also developed a detailed new patient assessment record which identified patients who may be at risk of female genital mutilation (FGM) and a register of children in this risk category was maintained. There was also a clinical lead specifically for this area. Safeguarding information and related issues were widely promoted throughout the practice for both patients and staff.

• The practice offered outreach clinics in a variety of settings including homeless shelters, hostels and encampment sites. The staff attending offered general health checks, care for immediate health needs, wound dressings, childhood and flu vaccines, screening services and treatments as necessary.

• Due to the health and social care needs of their patient population the practice had an exceptionally high incidence of chronic venous leg ulcers. Because of the patients lifestyle it had been assessed as unsafe for these patients to be referred to the district nurse for home visits. The practice therefore offered a walk-in leg ulcer clinic three times per week to meet the needs of these patients.

• The practice offered a walk-in service for the supply of condoms. Public health policy stated this was to be offered to patients under 19 years of age but due to the health issues and associated risks of the patient population they offered this service to all patients irrespective of age.

• To enable them to capture and deliver necessary care and treatment as soon as possible the practice had implemented a thorough new patient assessment process. This process included a full health and social care needs assessment and any treatment, blood tests or health reviews which were necessary at the same appointment. A detailed template had been developed to assist the assessment and to assist the practice to identify those who may be at risk of sexually transmitted diseases, blood borne viruses, FGM and safeguarding issues. An hour long appointment was scheduled for new patients to enable the staff to complete the assessments. This process reduced the need for patients to re-attend for routine screening and increased the chances of identifying patient’s health needs and providing interventions to reduce risks to patients and others. The practice had completed 961 of these new assessments in the last 12 months.

• If a patient attended for an appointment they would check if reviews, routine blood tests or treatment were due and complete these at the same time.

• The homeless were able to use the practice as a mail point which allowed the receipt of mail such as hospital appointments and benefits.

• The practice assisted with social needs such as benefits, housing and asylum issues and acted as patients advocate. They also helped with taxi fares for hospital appointments and for attending the surgery.

• The practice provided a food and clothes bank and provided winter rescue packs for the homeless. They worked closely with charitable organisations and businesses for donations for these areas of work.

• The practice had developed a community allotment in the grounds at Rosehill Medical Centre. They had provided raised beds and a potting shed. This was run by an organisation called Rotherham in Root and the practice supported them by providing seeds and administration services such as printing. This project had been developed for the benefit of the community and the food grown was shared between the community and a homeless shelter. Patients were also given seeds to grow their own produce.

• Although the practice did not offer appointments at weekends The Gate Surgery opened on a Saturday in the winter months to offer soup, warmth and a meeting place for vulnerable patients. This service was operated by staff on a voluntary basis.

The areas where the provider must make improvement are:

• Improve  systems to manage blank prescriptions and ensure these meet NHS Protect guidance.

• Improve storage arrangements for vaccines to ensure these meet Public Health England guidance. Review arrangements for monitoring the temperature of vaccines when they are transported from the surgery.

The areas where the provider should make improvement are:

• Implement refurbishment and maintenance plan at Rosehill Medical Centre to ensure effective infection prevention and control can be maintained.

• Review security arrangement at the branch surgeries to control access

• Include in complaint response letters to patients how to escalate a complaint if they are not satisfied with the response from the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice