Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. The practice was previously inspected by the CQC on 25 April 2017. At that inspection the rating for the practice was Inadequate overall. This rating applied to Safe, Well- led and all six population groups. Safe, Effective and Responsive were rated as requires improvement and caring was rated as Good. Following the inspection the practice was placed into special measures for six months and warning notices were issued. The report stated that the practice must address the following issues:

• The practice did not discuss serious untoward incidents either in a designated meeting or as a standing item in clinical meeting. The policy had not been updated in line with the practice’s own review timelines.

• Some equipment, specifically all but one of the blood pressure monitors, had not been calibrated in the last year.

• None of the staff who acted as chaperones had received chaperone training. They had not received DBS checks.

• The practice was clean. However, the practice did not have a cleaning checklist in place and sharps bins were not fixed or dated.

• All emergency drugs were stored outside of their boxes in small quantities, and as such it was impossible determine the expiry dates of any medicines in pill form. The vaccine fridge was overstocked and medicines were pushed to the side and the back.

• The practice did not have a failsafe system for monitoring 2 week wait referrals.

• The practice did not have a system of audit in place outside of medicines audits requested by the CCG, and were not able to provide copies of completed audits.

• The practice received updates from NICE, MHRA and the GMC but there were no formal mechanisms to review them.

• The practice held MDT meetings with health visitors and had attempted to arrange regular meetings with district nurses. However, there were no meetings with palliative care or mental health team.

• There was no PPG in place, although the practice was small and had been trying (on an ad hoc basis) to recruit members for a meeting.

• Policies were overdue review and on the day of the inspection management staff were unable to locate policies and procedures quickly. Safeguarding policies and procedures were not available on the day of the inspection but were provide the following day.

• The practice was not fully advertising it’s complaints procedure. There had been no complaints in the last 18 months.

The areas where the provider should make improvements were:

• Improve the identification of carers among the patient list.

• Review accessibility of services for patients with a hearing disability and those patients that do not speak English as their first language.

We carried out an announced comprehensive inspection at The Trafalgar Surgery on 30 January 2018. We found that the practice had made improvements following the last inspection, and it is now rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at The Trafalgar Surgery on 30 January 2018 as part of our inspection programme. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• The practice had implemented defined and embedded systems to minimise risks to patient safety.
• 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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Information about services and how to complain was available.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Alert patients when the practice is closed for training events.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 Trafalgar Surgery on 25 April 2017. This practice was registered in September 2016 when the previous provider left the practice and the current principal took over responsibility for the practice. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were either not in place or were not sufficiently clear to keep them safe. For example, medicines expiry dates were unclear, vaccines were not stored safely and not all equipment was calibrated.

• Although the practice carried out investigations when there were unintended or unexpected safety incidents, lessons learned were not communicated and so safety was not improved. The practice did not review significant events formally so as to ensure that all events were being identified and responded to as required.

• Patient outcomes were in line with national averages, however there was no evidence of formal recall systems

• There was limited quality improvement in place and there was limited evidence that the practice was comparing its performance to others; either locally or nationally.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity although there was a lack of systems for identifying carers.

• Patients were able to access appointments at short notice.

• Details of the formal complaints process were not made available to patients. The practice could therefore not be assured that all relevant formal complaints were being picked up.

• The practice had a clear leadership structure but had a limited formal governance framework, inaccessible policies and no active patient participation group.

The areas where the provider must make improvements are:

• Develop effective systems and processes to ensure safe care and treatment including ensuring that staff have access to safeguarding policies and significant event processes are clear and are reviewed. This should also include developing clear risk management is in place (including in relation to infection control), and improving medicines management processes and medicines storage.

• Develop effective systems and processes to ensure good governance including development of formal recall systems, development of quality improvement systems, ensuring that patients were aware of the formal complaints process, an improvement of the governance framework (including clarifying access to policies and procedures) and developing patient participation.

The areas where the provider should make improvement are:

• Improve the identification of carers among the patient list.
• Review accessibility of services for patients with a hearing disability and those patients that do not speak English as their first language.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice