This practice is rated as Good overall and in the safe domain. (Previously inspected March 2018 where it was rated as good overall and requires improvement in Safe)

From the inspection in March 2018 the practice was told they must:

• Ensure care and treatment is provided in a safe way to patients. By ensuring that actions required from the planned full fire risk assessment are implemented.

The full comprehensive reports can be found by selecting the ‘all reports’ link for The Molebridge Practice on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 7 March 2019, 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 March 2018. This report covers our findings in relation to those improvements made since our last inspection.

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.

The practice is rated as good overall and good for all the population groups.

The key question is now rated as:

Are services safe? – Good

At this inspection we found: -

• Fire alarms had been fitted throughout the building and all rooms contained smoke alarms.
• All staff had received fire safety training.
• A more in-depth fire risk assessment had taken place and the required actions completed.
• Fire evacuations had taken place and there was a weekly testing of fire alarms.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

Our previous follow-up inspection at The Molebridge Practice on 3 August 2017 found breaches of regulations relating to the safe and responsive delivery of services. The overall rating for the practice was requires improvement. Consequently we rated all population groups as requires improvement.

The practice had been previously inspected in August 2015, November 2015 and March 2016. The full comprehensive reports on the previous inspections can be found by selecting the

‘all reports’ link for The Molebridge Practice on our website at www.cqc.org.uk.

This inspection was an announced follow-up inspection carried out on 21 March 2018 to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made. This report covers our findings in relation to only those requirements found within the safe and responsive domains. At this inspection, we found the practice had made improvements but remains as required improvement for providing safe services.

Overall the practice is now rated as Good.

Our key findings were as follows:

• The practice had re-engaged with patients through re-establishing the patient participation group and linking with a local Leatherhead social media page and the local resident association.
• Patient comments in relation to appointments had been reviewed and a new appointment system put in place to provide more on the day appointments.
• The practice had started to review fire safety precautions and had completed some quick fixes. A full risk assessment had been planned for 22 March 2018. However, this meant that at the time of the inspection the concerns raised from our last inspection had not been fully addressed.

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

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients. By ensuring that actions required from the planned full fire risk assessment are implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at The Molebridge Practice on 22 March 2016 found breaches of regulations relating to the safe, caring and responsive delivery of services. The overall rating for the practice was requires improvement. Specifically, we found the practice to require improvement for provision of safe, caring and responsive services. It was good for providing effective and well led services. Consequently we rated all population groups as requires improvement. The practice had been removed from special measures after the March 2016 inspection.

The practice had been previously inspected in August 2015 and November 2015. The full comprehensive reports on the previous inspections can be found by selecting the ‘all reports’ link for The Molebridge Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 3 August 2017 to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.

At this inspection, we found the practice had made some improvements. However, there were areas highlighted during the previous inspections where improvements are still required. We have amended the rating for this practice to reflect these changes. Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for the provision of safe and responsive services. It was good for providing effective, caring and well led services. Consequently we rated all population groups as requires improvement.

Our key findings were as follows:

• The practice had developed a health and safety policy in June 2016 and carried out health and safety audit in May 2017. Staff we spoke with informed us they knew how to access information and guidance relevant to the health and safety processes.
• Staff had undertaken fire safety and health and safety training.
• There were inconsistent arrangements in how risks were assessed and managed. For example during the inspection we found risks relating to fire safety arrangements at Fetcham Medical Centre.
• The practice had demonstrated improvement in a number of areas during recent national GP patient survey results published on 6 July 2017.
• The practice had gathered feedback from patients through internal survey.
• The practice had not collected feedback. On the day of inspection the practice informed us that patient participation group (PPG) was inactive. Staff we spoke with were not able to provide any evidence to demonstrate that they had tried to engage with the PPG in the last 12 months.
• Staff we spoke with were not able to provide sufficient evidence to demonstrate that they were collecting and monitoring patients’ feedback through friends and family test (FFT) results.
• The GP partner told us the nurse practitioner roles had been implemented to address difficulties associated with recruiting additional GPs. The nurse practitioner roles had enabled GPs to provide more time in supporting patients with complex needs and focus on clinical monitoring and governance.
• Information about services and how to complain was available and easy to understand.
• Staff we spoke with on the day of inspection informed us there was a clear leadership structure and they felt supported by the management.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients. For example, review and improve the systems in place to effectively monitor fire safety procedures at Fetcham Medical Centre.
• Review patients’ feedback regarding the appointments booking system and improve the availability of appointments with preferred GPs to ensure the continuity of care with GPs.
• Ensure feedback from patients is sought and acted upon.

The areas where the provider should make improvements are:

• Continue to monitor and improve the appointment booking system in place and the time it takes for responses from the duty clinician. 

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 focused inspection of The Molebridge Practice on 17 November 2015.

We had previously carried out a comprehensive inspection of The Molebridge Practice on 26 August 2015. Breaches of regulations were found and the practice was required to make improvements. Following the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulations. We undertook this focused inspection on 17 November 2015 to check that the provider had followed their action plan and to confirm that they now met the regulations in relation to the safe management of medicines and staff recruitment checks.

This report only covers our findings in relation to those requirements. A further comprehensive inspection will be undertaken to follow up the remaining breaches of regulations and to check that improvements have been made. At this stage the overall rating for the practice will remain unchanged. You can read the report from our last comprehensive inspection by selecting the 'all reports' link on our website at www.cqc.org.uk

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

• The practice had developed processes to ensure that all necessary recruitment checks were carried out and recorded as part of the recruitment process.

• The practice had developed systems to ensure the safe management of medicines. This included processes for monitoring expiry dates and storage temperatures of medicines and the secure storage of prescription pads.

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 of The Molebridge Practice on 26 August 2015. Overall the practice is rated as inadequate. Specifically, we found the practice to be inadequate for providing safe and well led services. The practice was also inadequate for providing services for older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). The practice required improvement for providing effective and responsive services. It was good for providing a caring service.

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

• The practice worked closely with other organisations and with local community services in planning how care was provided to ensure that they met people’s needs.
• The practice provided care to a high number of vulnerable patients within the local community.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Appropriate recruitment checks on staff had not been undertaken prior to their employment. Staff in key roles had been employed without recruitment checks being undertaken.
• Staff felt well supported but had not always received training appropriate to their roles. Further training needs had not always been identified and planned. Some staff had not received an induction or regular appraisal of their performance.
• Medicines were not well managed within the practice and the practice could not be sure that all medicines were safe for use. There was a lack of processes for monitoring expiry dates and storage temperatures of medicines. Prescription pads were not stored securely.
• Emergency equipment was poorly maintained and monitored.
• There was a lack of safeguarding arrangements in place to protect vulnerable adults and children. Staff had not received training in the safeguarding of vulnerable adults. Clear policies were not in place to provide support and guidance to staff in the safeguarding of vulnerable adults and children.
• Risks to staff, patients and visitors were not always formally assessed and monitored.
• There was a lack of reporting of incidents, near misses and concerns. There was minimal evidence of learning and communication with staff.
• Meetings within the practice were informal. There were no agendas for meetings and minutes were often not recorded.

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

Importantly, the provider must:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure criminal records checks via the Disclosure and Barring Service are undertaken for all staff who are assessed as requiring a check, such as staff who act as chaperones.
• Ensure that medicines are securely stored and that fridge temperatures are monitored to ensure the cold chain is maintained.
• Ensure the security and tracking of blank prescription pads at all times.
• Ensure staff have access to adequate and well maintained emergency equipment.
• Ensure arrangements are in place to safeguard vulnerable adults and children from abuse.
• Ensure clear processes for the recording, review and learning from significant events, incidents and complaints.
• Ensure there are formal governance arrangements in place, including systems for assessing and monitoring risks and the quality of the service provision.
• Implement systems to ensure all clinicians are kept up to date with national guidance and clinical guidelines.
• Ensure audits of clinical practice are undertaken and that audit cycles are completed.
• Ensure assessments of risk are undertaken and that recommendations are implemented, in order to reduce the risk of exposure of staff and patients to legionella bacteria.
• Ensure the availability of appropriate sharps containers and the correct labelling of sharps containers in use.
• Replace expired spillage kits and other expired consumables within the practice.
• Ensure rehearsal of the practice fire evacuation procedures.
• Ensure staff undertake training to meet their needs, including training in the safeguarding of vulnerable adults, health and safety, fire safety, chaperoning, the Mental Capacity Act 2005 and infection control.
• Provide opportunities for all staff to receive induction, regular supervision and appraisal.
• Ensure records of practice and multidisciplinary meetings are kept and reviewed.

In addition the provider should:

• Ensure the practice gathers feedback from patients by conducting a patient survey which is accessible to the whole practice population.
• Develop an action plan to ensure findings from the infection control audit are reviewed and implemented.
• Define parking spaces within the practice car park for patients with a disability.
• Provide signage to promote the practice chaperone service within consulting rooms.
• Utilise the practice electronic record system to alert staff to patients associated with children or adults who have been identified as being at risk of abuse.
• Utilise translation services and information leaflets in different languages to provide support to patients whose first language is not English.
• Continue to regularly review the practice’s opening hours to ensure they meet the needs of patients.
• Develop a locum information pack to support locum GPs within the practice

On the basis of the ratings given to this practice and the concerns identified at this inspection we are taking enforcement action and are placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

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 Molebridge Practice on 22 March 2016. Overall, the practice is rated as requires improvement.

The Molebridge Practice was subject to a previous comprehensive inspection in August 2015 when the practice was rated as inadequate and was placed into Special Measures. Following our inspection of the practice in August 2015, the practice sent us an action plan detailing what they would do to meet the regulations. We undertook this comprehensive inspection on 22 March 2016 to check that the provider had followed their action plan and to confirm that they now met the regulations. We found that many improvements had been made since our previous inspection.

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

• There was an open and transparent approach to safety and improved, effective systems in place for reporting and recording significant events.
• Health and safety processes and procedures were not clearly defined. There was a lack of guidance for staff in this regard.
• The practice had commissioned a full survey to assess the risk of legionella in January 2016. The practice had reviewed the findings of the report and had taken action to minimise any risks.
• The practice carried out internal risk assessments for electrical equipment. Any concerns or faults were reported to the practice manager who organised repairs or new equipment.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• The practice had implemented improved processes to ensure that staff had the skills, knowledge and experience to deliver effective care and treatment and were kept up to date with best practice guidance.
• 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 were able to access urgent appointments on the same day. However, patients continued to rate the practice below average for several aspects of their ability to access services.
• There was a clear leadership structure and staff felt supported by management.
• The practice proactively sought feedback from staff and patients. The practice implemented suggestions for improvements and made some changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Implement clear procedures for staff to support health and safety processes within the practice.
• Ensure further action is taken in response to feedback gathered from patients, in order to improve access to the practice.

The areas where the provider should make improvements are:

• Implement processes to ensure that complaints information and correspondence is accessible and can be readily reviewed in order to promote continuous improvement.

I confirm that this practice has improved sufficiently to be rated requires improvement overall. The practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice