Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of The Pulteney Practice on 19 January 2016. We did not inspect the branch surgery at Bathampton (address: 29 Holcombe Lane, Bathampton, Bath BA2 6UL). During this inspection an overall rating of good was made, with the effective, caring and well led areas all being rated as good and the responsive domain as outstanding. Following the inspection we issued a requirement notice. The notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment.

The issues were:

• The provider must ensure all appropriate emergency medicines were available, and stored for easy access. Regular checks were required to confirm these medicines were in date and what were safe to use.

• The provider must ensure that all medicines in the GP’s home visit bags and the controlled drugs held at the practice were in date and were accounted for.
• The provider must ensure out of date medicines are disposed of appropriately, in line with guidance from the Royal Pharmaceutical Society.
• The provider must ensure that requirements for the management of prescription paper security are met at all times.
• The provider must ensure that they reviewed and updated the practice fire evacuation procedures, maintain an appropriate frequency of fire alarm testing and fire drills, and update fire safety documentation appropriately.

In addition the provider should:

• Ensure that spill kits are available to deal with breakages so that guidelines on the cleaning of hazardous substances and samples are met.
• Assess its compliance with the Equality Act 2010, with respect to disabled access to the premises and any deficiencies should be addressed where possible.

The full comprehensive report on the 19 January 2016 inspection can be found by selecting the ‘all reports’ link for The Pulteney Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 January 2017 to confirm that the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 19 January 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall the practice is now rated as good.

Our key findings across all the areas we inspected during this inspection, were as follows:

• We saw that the practice had policies in place for the storage of medicines, including controlled drugs and for checking emergency drugs in the practice. All appropriate emergency medicines and equipment were present, including emergency medicines for the management of diabetic conditions and also for some heart conditions. We found that all medicines in the GP home visit bag were accounted for, in date and safe to use.

• When we spoke to the practice they informed us that controlled drugs were no longer kept on site and showed us records to confirm that. All out of date medicines were disposed of appropriately, in line with guidance from the Royal Pharmaceutical Society.

• We saw evidence that prescription paper security was safely managed.
• We saw evidence that the provider had reviewed fire evacuation procedures, including updating information on fire alarm testing and records of fire drills.

Our findings regarding actions that the provider should take as a result of our last inspection were as follows:

• We saw that spill kits were available to deal with breakages so that guidelines on the cleaning of hazardous substances and samples were met, with up to date records.
• The provider had carried out an assessment of its compliance with the Equality Act 2010, with respect to disabled access to the premises and addressed deficiencies regarding access. This included assessing the premises for safe evacuation in the event of a fire from the first floor building.

Following this inspection the practice was rated overall as good across all domains.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Pulteney Practice on 19 January 2016. We did not inspect the branch surgery at Bathampton. Overall the practice is rated as good. We found the practice requires improvement for safe services.

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. However, we found some gaps in the management of fire safety.
• Risks to patients were assessed and well managed, with the exception of those relating to medicines management.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• 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 some policies and procedures were not consistently implemented.
• 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.

We saw some areas of outstanding practice:

The practice has a higher than average population of older patients and provided effective services to support them, coordinated with other organisations. These included the Hale and Hearty scheme, the Blue Triangle scheme, which is a service tailored for those with a diagnosis of dementia. The provider undertook pro-active work to identify ‘off-radar’ patients, avoid unplanned hospital admissions and support discharge from hospital. There was active identification of needs and support to specific populations including transient groups and victims of domestic violence. GPs are supported by Personal Assistants and ensure effective, daily communication within the practice team and with patients. We saw very positive feedback from patients regarding these services; and the practice was actively seeking to expand such services.

The areas where the provider must make improvement are:

• Ensure all appropriate emergency medicines are available, ensuring that these are stored for easy access; and that regular checks confirm what is available and that these medicines are safe to use.

• Ensure all medicines in the home visit bags and controlled drugs are in date and are accounted for. Any out of date medicines must be disposed of appropriately, in line with guidance from the Royal Pharmaceutical Society.

• The practice must ensure that requirements for the management of prescription security are met at all times.

• The practice must review fire evacuation procedures, frequency of fire alarm testing and records of fire drills; and update documentation appropriately.

The areas where the provider should make improvement are:

• The practice should ensure that requirements for the safe cleaning of hazardous substances and samples are met.

• An assessment of compliance with the Equality Act 2010 should be undertaken with respect to disabled access to the premises and any deficiencies should be addressed where possible.

Professor Steve Field  CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During our visit to The Pulteney Practice we met and talked with eight people who were patients across both surgeries. We also met and talked with four GPs, the practice manager and deputy manager, two practice nurses, and three administration staff. The people we met were happy with the service they received as patients. Comments made included: "the practice is very good", "this is an exceptional practice", and "I would never want to go anywhere else." A person we asked about making appointments said: "this is a really efficient practice. I can always get to see someone and I need to come often." All the people we met said they could get an appointment to suit them, including in an emergency. Another person said: "I would definitely recommend them. They are very caring and always have been for me and my family."

We found the practice treated people with consideration and respected their privacy and dignity. People were encouraged to maintain their independence and make their own informed decisions about any treatment. People were given time and listened to so their needs could be assessed and any treatment or support centred on them.

All staff were trained and experienced to enable them to respond appropriately to any allegation or suspicion of abuse of a vulnerable adult or child. Staff were experienced and skilled in their different roles. Most training was up to date and staff were supported to carry out their roles and responsibilities safely and effectively.

Some areas of the surgery in Great Pulteney Street did not fully meet infection prevention and control standards. Otherwise both surgeries were clean and well organised in all patient areas. There were some issues with access for frail or disabled people at the entrance to the building in Great Pulteney Street. There was good access to the modern purpose-built Bathampton surgery.