Letter from the Chief Inspector of General Practice

We had previously carried out an announced comprehensive inspection at The Village Surgery on 13 December 2017. Overall the practice was rated as inadequate and placed in special measures. We identified concerns with regards to safe, effective and well-led care provided by the practice. We served warning notices under regulations 17 (good governance) and 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The report for the comprehensive inspection can be found by selecting the ‘reports’ link for The Village Surgery on our website at: https://www.cqc.org.uk/location/1-540434907 .

The practice sent us a plan of action to ensure the service was compliant with the requirements of the regulations. We undertook a focussed inspection on 19 June 2018 to review the breaches of regulation identified at the inspection in December 2017 and to ensure the service had made improvements. At this inspection we did not review the ratings for the key questions; we will consider the practice’s ratings when we carry out a comprehensive inspection at the end of the period of special measures.

At the inspection on 19 June 2018 we found that the practice had made significant improvements and were no longer in breach of regulations 12 and 17.

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

• Pathology results were solely managed by GPs and there was a newly implemented policy that detailed the process.
• The practice were able to demonstrate there was an effective system in place for infection prevention and control.
• We found that communication in the practice had improved, there were regular staff meetings and outcomes and actions were documented.
• There was a suite of practice specific policies available for all staff.
• We found that the systems for managing patient safety alerts, significant events, complaints, DBS checks, fire safety and uncollected prescriptions were significantly improved.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – requires improvement

Are services caring? – good

Are services responsive? – good

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. Because of the concerns identified under safe and well-led the population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

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

We carried out an announced comprehensive inspection at The Village Surgery on 22 October 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the October 2015 inspection can be found by selecting the ‘all reports’ link for The Village Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 13 December 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 22 October 2015.

Our key findings were as follows:

The practice had remedied some of the shortfalls identified at our previous inspection but not all; in addition significant new concerns and regulatory breaches were identified at this inspection.

• The system for managing pathology results was informal and lacked GP clinical oversight and quality assurance.
• There were no protocols in place for medical emergencies, management of high risk medicines, business continuity planning, patient safety alerts and uncollected prescriptions.
• There was an ineffective system for managing disclosure and barring service (DBS) checks for staff.
• There was an ineffective system in place for managing staff training, the practice were only able to provide limited evidence of training.
• There was no fire risk assessment completed since 2015 and the practice did not carry out fire drills.
• Significant events were recorded and learning outcomes were identified; however learning was not shared with all staff.
• There was no clinical oversight for uncollected prescriptions.
• There were gaps in governance systems, internal meetings were not held on a regular basis and minutes were not made available to all staff when meetings were held.
• More than one percent of the patient population had been identified as carers.
• National GP survey results showed that patient satisfaction in all areas was mostly above the local and national averages.

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

In addition the provider should:

• Include information about the role of the Health Services Ombudsman in its responses to complaints.
• Review the audit system in relation to the monitoring of prescription pads in accordance with national NHS guidelines.
• Ensure a disability discrimination access assessment is completed.
• Review the current system with a view to improve the uptake of childhood immunisations.
• Review the system for monitoring and improving outcomes for patients with long-term conditions.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Village Surgery on 22 October 2015. Overall the practice is rated as requires improvement.

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. However, reviews and investigations were not thorough enough and people did not always receive a verbal and written apology.
• Risks to patients were assessed and well managed, with the exception of those relating to infection prevention and control (IPC) and pre-employment checks.
• Data showed some patient outcomes were low for the locality such as the care for people with diabetes and hypertension.

• Clinical audits demonstrated quality improvement.

• Patients said they were treated with compassion, dignity and respect.
• Urgent appointments were usually available on the day they were requested and routine appointments with a GP were usually available within three working days.
• Patient survey feedback was above local and national averages regarding appointments access.
• Practice specific policies were up to date and readily available to all staff but some had not been implemented. For example some staff members had not received annual infection prevention and control training which was not in accordance with the practice’s policy.
• The practice’s patient participation group (PPG) had not met for more than 12 months. The practice could not demonstrate that it had proactively sought feedback from patients.

The areas where the provider must make improvements are:

• Undertake infection prevention and control audits so that risks are identified and acted upon.
• Ensure recruitment arrangements include all necessary pre-employment checks such as DBS checks and risk assessments for staff undertaking chaperoning duties.

In addition the provider should:

• Reconvene its PPG so that it can proactively seek patients’ views on how the service is delivered.

• Review its significant events reporting and recording systems to ensure they are being identified, recorded, used to identify risks and continuously improve patient safety.

• Introduce a system for checking expiry dates of emergency medicines.
• Demonstrate systems for support to patients when things go wrong.

• Ensure there is a record of clinical meeting discussions so as to enable reflection on outcomes being achieved and to identity improvement areas such as regarding performance on diabetic care and hypertension.  

• Undertake Control of Substances Hazardous to Health (COSHH) risk assessments.

• Review systems for updating and monitoring QOF performance; particularly care for people with diabetes and hypertension; and consider working more closely with its Clinical Commissioning Group in this regard.
• Ensure that induction takes place for all newly appointed members of staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

This comprehensive inspection was undertaken on 13 September 2018 following a period of special measures, the practice is now rated as good. (Previous rating December 2017 – Inadequate)

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

We had previously carried out an announced comprehensive inspection at The Village Surgery on 13 December 2017. Overall the practice was rated as inadequate and placed in special measures. We identified concerns with regards to safe and well-led care provided by the practice.

We served a Warning Notice under regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The report for the comprehensive inspection can be found by selecting the ‘reports’ link for The Village Surgery on our website at: .

The practice sent us a plan of action outlining how it would become compliant with the requirements of the regulations. We undertook a focussed inspection on 19 June 2018 to review the breaches of regulation identified at the inspection in December 2017 and to ensure the service had made improvements. At the focussed inspection we found that the practice was compliant with the regulatory breaches we had identified at the comprehensive inspection in December 2017. The report for the focussed inspection can be found by selecting the ‘reports’ link for The Village Surgery on our website at: .

This report relates to the follow up comprehensive inspection carried out on 13 September 2018. At this inspection we found that the practice had sustained the improvements we had noted at our focussed inspection in June 2018.

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

• There was a comprehensive system in place to ensure the safe management of high risk medicines.
• Improvements to governance systems had been made. For example, the practice was able to provide evidence that processes for managing pathology results and patient safety alerts were improved and staff were adhering to the improved protocols.
• Systems for managing staff training and induction were significantly improved.
• Patient feedback was significantly above the local and national averages.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• 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 practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice