This practice is rated as good overall.

(August 2017 – Good. December 2017 – requires improvement for providing safe services)

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? - Good

We carried out an unannounced focused inspection at The Moat House Surgery on 14 December 2017. This inspection was carried out to follow up concerns that had been received to CQC regarding prescribing processes. We rated the practice as requires improvement for the provision of safe services because breaches of regulation were identified

This inspection was an unannounced focused inspection carried out on 17 July 2018 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 14 December 2017. This report covers our findings in relation to those requirements.

Overall the practice remains rated as good. However, we found the practice continues to require improvement for the provision of safe services.

At this inspection we found:

• The practice had started a process to review and update all policies and protocols.
• The practice had systems and processes to monitor the prescribing of medicines, including for high risk and controlled drugs. However, these were not always implemented and operating effectively.
• Staff had received training regarding policy changes made relating to repeat prescribing, high risk medicines and controlled drugs.
• Staff told us they felt morale had improved at the practice and they were supported by management.

The areas where the provider must make improvements as they are in breach of regulations:

• Ensure care and treatment is provided in a safe way to patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We undertook an unannounced focused inspection at The Moat House Surgery on 14 December 2017. This inspection was carried out to follow up concerns that had been received to CQC in regards to prescribing processes.

Previously we carried out a focused inspection at The Moat House Surgery on 10 August 2017 to follow up non-compliance in the safe domain. The overall rating for the practice was good. The full comprehensive report on the July 2016 inspection and the focused report for August 2017 can be found by selecting the ‘all reports’ link for The Moat House Surgery on our website at www.cqc.org.uk.

Overall the practice remains rated as good with requires improvement for providing safe services.

Our key findings were as follows:

• The practice had reviewed prescribing processes and implemented changes.
• The practice had put new systems in place to monitor prescribing of high risk medicines and controlled drugs however these systems were not sufficient to keep patients safe.
• The practice had a strong culture of recording and learning from significant events and near misses.
• The practice had a suite of policies and protocols available to staff, however not all of these were up to date.

There were also areas of practice where the provider needs to make improvements.

• Importantly, the provider must:

Establish effective systems and processes to ensure that care and treatment is provided in a safe way for service users. By:-

• Ensuring that policies and protocols, including those relating to medicines, contain up to date information and reflect current practice to mitigate any risk.
• Ensuring the proper and safe management of medicines by having effective systems in place to manage prescribing of high risk medicines.

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 Moat House Surgery on 29 July 2016. The practice was rated requires improvement for the provision of safe services. The overall rating for the practice was good. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for The Moat House Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 August 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 29 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for providing safe services.

Our key findings were as follows

• Every area highlighted as requiring improvement (including areas where they should improve) had been escalated as a significant event to ensure the processes and policies were reviewed and learning shared with staff.
• Recruitment arrangements included all necessary employment and background checks for all staff.
• There was a system for checking emergency equipment and medicines so they were within their expiry date and fit for use. The practice had also reviewed the emergency medicines and equipment to ensure it was in line with recommended best practice guidance.
• Designated staff had been trained in legionella awareness and all actions in the legionella risk assessment had been completed.
• Blank prescription forms were securely stored and tracked throughout the practice.
• Chaperone training had been undertaken by all staff that were designated chaperones and staff were aware of their responsibilities. All staff who were chaperones had a DBS check.

The practice showed us their overall (unverified) exception reporting figures for 2016/17 (exception reporting is the removal of patients from Quality and Outcomes Framework (QOF) calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). (QOF is a system intended to improve the quality of general practice and reward good practice). The practice had reported 15% total clinical exceptions which had reduced from 17% in 2014/15. This remained higher than the 2015/16 Clinical Commissioning Group average of 11% and national average of 10%. Diabetes and cervical smear screening indicators exceptions had improved but remained above local and CCG averages.

Since the last inspection the practice had reviewed their QOF achievement and exception reporting rates and had made a number of changes to improve patient outcomes. They had reviewed the nursing skill mix and offered additional training to enhance the skills of one of the practice nurses. The practice provided additional staffing at their annual flu clinics to enable patients with long term conditions to receive health and lifestyle checks included in their annual long term condition reviews. A system flag was raised for any patient who had not responded to repeated requests to attend for reviews so clinicians could offer opportunistic reviews.

Since the last inspection the practice had reviewed their confidentiality policy and ensured all staff were aware of their responsibilities. Staff we spoke to were able to demonstrate how they hold confidential conversations and keep patient notes safe and secure on the computer system.

However, there was an area of practice where the provider should make improvements:

• Continue to monitor and improve QOF exception rates to ensure patients receive appropriate care and treatment.

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 Moat House Surgery on 29 July 2016. Overall the practice is rated as good.

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

• 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.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks, training, Legionella risk assessment and stock checking including emergency equipment and medicines.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, and that they could access urgent appointments the same day through the triage system.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a number of policies and procedures to govern activity.

We saw one area of outstanding practice:

• When registering with the practice patients were offered an induction with the patient services manager. This induction gave patients a clear understanding of how the practice worked including how to book appointments and which clinics were offered, which empowered patients to access the care they required in a timely manner. It also allowed the practice to identify patients who might need additional support such as carers, patients with long term conditions and patients who were homeless. This allowed early onward referral or signposting to other services and had demonstrated positive patient outcomes.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure there is a robust system in place for stock checking including emergency equipment and medicines.
• Ensure recruitment arrangements include all necessary employment checks for all staff, including references. Ensure that action is taken to mitigate the risks identified in the Legionella risk assessment.
• Ensure that prescription forms are stored securely and tracked within the practice.

In addition the provider should:

• Review processes to ensure patients with long term conditions receive the best care.
• Ensure that patient confidentiality is maintained.
• Review chaperone training and the way in which chaperones are used to ensure it meets best practice guidelines. Also review the risk assessments that determine whether a Disclosure and Barring Service check is required or not for administrative staff including those who act as chaperones to ensure it meets best practice guidelines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice