We carried out an announced comprehensive inspection at The Valkyrie Surgery as the practice was rated Requires Improvement at the previous inspection.

We based our judgement of the quality of care at this service 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.

We have rated this practice as good overall and good for all population groups.

We found that:

• The practice had adequately addressed the areas for improvement in the last report, including:
• The system for responding to patient safety alerts was effective.
• The learning from significant events and complaints was routinely shared with staff to avoid recurrence.
• Assessments of the risks to the health and safety of service users receiving care or treatment were appropriate, in particular there was an effective system in place for the storage of emergency medicines.

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

Continue to analyse the reported exception rates for patients with long term conditions to ensure all data is accurate.

Continue to work with community services to identify ways of improving the uptake for childhood immunisation.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall.

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? – Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

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

We carried out an announced inspection at The Valkyrie Surgery on 7 March 2018 as part of our routine inspection programme.

At this inspection we found:

• The practice had some systems to manage risk so that safety incidents were less likely to happen.
• Although significant events were identified and some actions taken to avoid repetition, there was little evidence of learning being disseminated.
• Complaints were handled appropriately however it was not always clear to see what actions had been taken to avoid repetition, and there was limited evidence of shared learning from these.
• Processes for monitoring patients prescribed high risk medicines were satisfactory.
• Several of the medicines expected to be kept by the practice in case of a medical emergency were not kept and there was no risk assessment completed to explain their absence.
• Although there was a system in place to deal with patient and medicine safety alerts, there was no clear ownership of the clinical alerts and therefore there was limited assurance that actions had been taken.
• There were systems in place to keep adults and children safeguarded from abuse, however staff found it difficult to easily access the contact details for referring on concerns relating to vulnerable adults.
• Equipment was calibrated and tested appropriately.
• There were infection control processes in place, although some staff did not know who the lead was for infection control. There was no check lists to show that ear irrigation equipment had been cleaned between uses.
• Care and treatment was delivered according to evidence- based guidelines.
• Published clinical performance data for the year 2016-2017 showed the practice performance was lower than the local and national average in several clinical areas.
• Unverified clinical performance data for the last performance year to date showed that the practice had made improvements with the majority of its clinical performance.
• The staff files we reviewed showed that the majority of staff had received appraisals and support, however the practice manager had not received an appraisal since 2016.
• The practice demonstrated strong multi-disciplinary working and a good awareness of its patients with the most complex needs.
• The practice was aware of its patient populations need and the staffing diversity reflected the diversity of the patients. Staff spoke a variety of different languages and were able to advise each other on cultural differences.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Staff felt supported and able to raise concerns. Both staff and patients we spoke to felt that if they raised concerns they would be listened to.
• There was a strong focus on continuous learning at all levels of the organisation.

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

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements:

• Ensure all staff receive appraisals necessary to support them to carry out their duties.
• Ensure staff have ready access to the contacts for referring on concerns relating to vulnerable adults.
• Inform all staff of the relevant clinical leads and their deputies when any staffing changes are made. Ensure policies are kept up to date and read by staff.
• Implement a system for recording the cleaning of ear irrigation equipment.
• Review systems relating to cervical screening to improve the uptake of this screening.
• Continue to review and improve the systems relating to performance for patients with diabetes. Review levels of exception reporting.
• Monitor and improve patient satisfaction in relation to nurse consultations and access to the practice by telephone.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried an announced focused inspection at the practice on 15 January 2016. This inspection was carried out to check improvements made following our comprehensive inspection, which was carried out on 7 July 2015. At that time we identified areas which required improvement within the safe domain. We issued a requirement notice under Regulation 19 of the Health and Social Care Act 2014 in relation to improvements that were required when recruiting new staff.

Additionally we identified some areas where the provider should make improvements. These were around more detailed recording of significant safety events and reviewing policies and procedures so that they were up do date and reflected current best practice and relevant guidance.

The overall rating for the practice was good.

When we visited the practice on 15 January 2016 we reviewed the improvements made by the practice within the safe domain. We found:

• Improvements had been made in how new staff were recruited to work at the practice. All of the appropriate checks including employment references, proof of identification and disclosure and barring services (DBS) checks had been carried out.
• Improvements had been made in how risks were assessed and managed. Where non-clinical staff did not have a DBS check the practice had conducted a risk assessment to determine the level of risk and to provide a rationale for their decision.
• Audits were carried out to test the effectiveness of infection control procedures within the practice.
• Records were detailed in respect of how significant events were investigated, reviewed and how this information was shared with staff to support improvements.
• The practice policies and procedures were under review so that they were up to date, specific to the practice and in line with current guidance and best practice.

Following our inspection we rated the safe domain as good. This report should be read in conjunction with the 7 July 2015 comprehensive inspection report.

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 Valkyrie Surgery on 7 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective and responsive and caring services. It was also good for providing services for older people, people with long term conditions, families, children and young people, working aged people (including those recently retired and students), people whose circumstances make them vulnerable and people with mental health (including people with dementia).

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Patient and staff safety was maintained through learning and improving from when things went wrong.
• The practice had procedures for safeguarding vulnerable adults and children. Staff were trained and the practice had dedicated lead staff to oversee these procedures. The practice had arrangements for chaperoning patients and all staff had undertaken training. Non-clinical staff who occasionally undertook chaperone duties did not have a disclosure and barring (DBS) check in place.
• The practice had suitable arrangements for managing medicines safely. The practice provided electronic prescribing and patients could pick up prescribed medicines from a choice of local pharmacies.
• The practice had arrangements in place for minimising the risks of infection. There were policies and procedures in place and staff had undertaken training.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance and referrals to secondary care services were made in a timely way.
• Patients we spoke with said they were treated with empathy, compassion, dignity and respect. They said that they were listened to and involved in making decisions about their care and treatment. Results from the National GP Patient Survey 2015 indicated lower levels of patient satisfaction in relation to GPs and nurses listening to them and treating them with care and concern when compared to other GP practices locally and nationally.
• Information about services and how to complain was available and easy to understand and complaints were handled and responded to appropriately.
• Appointments were flexible to meet the needs of all patients. The practice performed in line with or higher than practices both locally and nationally for patient satisfaction with the surgery opening times, appointments system and ease of accessing appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff were supported by management. The practice sought feedback from staff and patients.

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

Importantly the provider must:

• Ensure that staff are recruited robustly with all of the required checks carried out including disclosure and barring services checks and employment references.

Additionally the provider should:

• Review the systems for recording significant and other safety events so that they describe in detail the analysis of the event and show that these events are reviewed to ensure that learning is embedded in staff practice.
• Ensure that all staff who undertake chaperone duties are risk assessed and if required the have appropriate checks to help determine their suitability to work with vulnerable adults and children
• Carry out regular infection control audits to test the effectiveness of the procedures in place to reduce the risk of infections and introduce cleaning schedules.
• Ensure that all policies and procedures are kept under regular review so that they are up to date and reflect the day to day running of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice