Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Vineyard Surgery on 27 October 2014. The overall rating for the practice was requires improvement. We identified breaches of regulations relating to staffing and the monitoring of safety and we issued requirement notices in relation to these breaches. Following the initial inspection the practice submitted an action plan outlining how they intended to address the breaches of regulation identified.

On 20 December 2016 we carried-out a follow-up announced comprehensive inspection at the practice. During this inspection we found that the issues identified during the previous inspection had been addressed; however, we identified further regulatory breaches in respect of the safety, effectiveness, caring, and leadership at the practice. We issued requirement notices in relation to breaches of Regulation 17 (Good governance) and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 

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

This inspection was an announced focused inspection carried out on 3 September 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 20 December 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 were as follows:

• Staff had the skills and knowledge to deliver effective care and treatment and a concise competency framework have been introduced for non-medical prescribers.
• Following the previous inspection in December 2016, security arrangements had been put in place to ensure that medicines and blank prescription stationery was securely stored.
• The practice had a good understanding of their performance, and had put processes in place following the previous inspection to improve. Data from the Quality and Outcomes Framework showed patient outcomes were at or above average compared to local and national averages.
• The practice had considered the results of the most recent patient satisfaction survey, but their action plan did not address concerns about the nursing service.
• During the December 2016 inspection we found that patient consent to treatment such as childhood immunisations was not always recorded in records. During the re-inspection we reviewed a sample of records and found that a record of consent had been made in all cases; however, in some records of childhood immunisations, there was no record of the identity of the person giving consent.
• Clinical audits demonstrated quality improvement.
• During the December 2016 inspection we found that there was a lack of consistency amongst staff about the process for chaperoning. When we re-inspected, we found that all staff we interviewed who acted as chaperones were clear about the process and all confirmed that they would stand inside the privacy curtain during examinations.
• During the December 2016 inspection we found that there was no record kept of cleaning completed by cleaners, and that the practice’s Infection Prevention and Control (IPC) lead was not up to date with IPC training. When we re-inspected we found that a log of cleaning had been put in place, and that the IPC lead was up to date with training; however, the practice did not keep a log of the cleaning of small clinical equipment. A recent IPC audit had been completed at the practice, and staff were in the process of considering the recommendations made.
• During the December 2016 inspection we noted that the practice had arrangements in place to provide language translation during consultations; however, this was not advertised in the waiting area. When we re-inspected we found that information was available about this service.
• During the previous inspection in December 2016 we found that the practice had identified 21 patients as carers, which represented less than 1% of the practice list. When we returned to the practice we found that there were 18 carers on their carers register. The practice had assigned a member of staff as a carers’ champion, with a view to increasing the profile of the support offered to patients.
• During the previous inspection we found that complaints about the practice were not always responded to in line with the practice’s complaints procedure. When we re-inspected we found that the practice had received one complaint since the last inspection, and this had been investigated and responded to in line with the practice’s complaints procedure. We noted that responses to complaints were co-ordinated centrally by the group manager to ensure consistency of approach and to enable shared learning across all four of the provider’s sites.
• The practice had assessed the needs of their local community, and was in the process of developing projects to address the needs of vulnerable patients. For example, they were about to begin donating GP time to a local charity for homeless people, to enable these patients to access medical care.

Areas where the practice should make improvements:

• Take action to further identify patients with caring responsibilities in order that these patients can be offered support.
• Consider the infection risks associated with the use of clinical equipment and machinery (such as stethoscopes and ear irrigators) and ensure that processes are in place to evidence that these risks have been mitigated.
• Monitor patient satisfaction of the nursing service to assess whether any further changes or improvements are required.
• Ensure that complete information is included in records of patient consent.

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 Vineyard Surgery on 27 October 2014. The overall rating for the practice was requires improvement. We identified breaches of regulations relating to staffing and the monitoring of safety and we issued requirement notices in relation to these breaches. Following the initial inspection the practice submitted an action plan outlining how they intended to address the breaches of regulation identified. The full comprehensive report on the October 2014 inspection can be found by selecting the ‘all reports’ link for The Vineyard Surgery on our website at www.cqc.org.uk.

We carried out a follow-up announced comprehensive inspection at The Vineyard Surgery on 20 December 2016. Overall the practice is rated as requires improvement.

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

• During the initial inspection in October 2014 we found that the practice had failed to ensure that learning from significant events was shared with staff. During the follow-up inspection we found there was a system in place for reporting and recording significant events; however, not all staff were aware of their responsibilities in relation to this. The provider was aware of the requirements of the duty of candour; however, this requirement was not sufficiently embedded into the culture of the practice to ensure that patients were always notified of incidents that affected them.
• During the initial inspection we found that the practice had failed to ensure that risks to patient safety were well managed; specifically, we found that they had failed to conduct regular infection control audits. During the follow-up inspection we found that risks at the practice were still not always well managed, specifically those relating to infection control, security and medicines management.
• During this inspection we found staff aimed to assess patients’ needs and deliver care in line with current evidence based guidance; however, we saw examples of the practice failing to act when alerted to problems in this area. We also found that some staff were not fully aware of their responsibilities in establishing whether a young person had capacity to make decisions about their care and treatment, and we saw an example of a patient’s consent to receiving treatment had not been appropriately recorded.
• During the initial inspection we found that the practice did not have suitable arrangements in place to support staff, and that staff did not receive regular supervision or appraisal. During the follow-up inspection we found that staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment and that all staff received an annual appraisal; however, we saw evidence that some members of staff were likely to be acting outside of their scope of competence and that there were not suitable arrangements in place for all staff to receive regular supervision.
• During the initial inspection we found that the practice did not have suitable recruitment procedures in place, as they did not have records of proof of identity, references, Disclosure and Barring Service checks or Hepatitis B status for all relevant staff. When we reviewed records during the follow-up inspection we found that all necessary recruitment records were in place.
• Data showed patient outcomes were comparable to the national average; however, the practice had a high exception reporting rate and had no plan to address this.
• 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. Processes were in place for lessons learned from complaints to be shared with staff.
• Overall, patients said they found it easy to make an appointment with a named GP and 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.
• There was a clear leadership structure and overall, staff felt supported by management. The practice was in the process of making changes to the terms and conditions in some staff members’ contracts, and was conducting a formal consultation with staff about this; however, some staff felt that they were not always consulted on changes that impacted them.
• The practice had a group of patients who they contacted electronically to gather feedback, but did not have a formal patient participation group.

The areas where the provider must make improvement are:

• Ensure that all staff are aware of their responsibilities with regards to reporting safety incidents, including their obligations under the duty of candour, and that they are familiar with the processes to be followed.
• Ensure that staff are only providing care and treatment with their competency and that all staff have a clear and well-defined scope of practice.
• Ensure that all staff are clear about their responsibilities in relation to assessing patients’ capacity to make decisions about their care and treatment, and that a record of consent given is made in patients’ notes.
• Ensure that adequate processes are in place to manage the risks of infection, including putting processes in place to monitor cleaning in the practice and ensuring that staff with specific infection control responsibilities are qualified to undertake their role.
• Ensure that resources, equipment and medicines are stored securely and in line with guidance and the processes are in place to monitor stock levels of emergency medicines.
• Put in place the correct legal paperwork to allow staff to administer medicines in line with guidance.
• Ensure that processes are in place to monitor the safety and performance of the practice, including gathering and acting on feedback from patients including analysing and acting on the results of the NHS patient survey and developing a patient participation group.

In addition, the practice should:

• Ensure that records are kept of the cleaning carried-out.
• Advertise the availability of language translation services to patients.
• Ensure that all staff carrying-out chaperoning duties are familiar with the requirements of their role.
• Take action to further identify patients with caring responsibilities in order that these patients can be offered support.
• Ensure that complaints are handled consistently and in line with the practice’s complaints policy.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

The Vineyard Surgery provides general medical services to approximately 3700 patients in Richmond, Surrey. It is one of two practices operated by this provider.

We visited the practice on 27 October 2014 and carried out a comprehensive inspection of the services provided.

We rated the practice as ‘Requires Improvement’ overall; ‘Good’ in the domains of caring and responsive and ‘Requires Improvement’ in the domains of safe, effective and well led. We rated the practice as ‘Requires Improvement' for all six population groups we looked at including older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

The practice provided a caring and responsive service. There was a good skill mix amongst staff at the practice. Patients’ needs were suitably assessed and care and treatment was delivered in line with current legislation and best practice. We saw from our own observations and heard from patients they were treated with dignity and respect. The practice understood the needs of its patients and was responsive to them.

Our key findings were as follows:

• Staff at the practice were aware of the need to report incidents, complaints and safeguarding concerns
• The number of incidents was low but where they had occurred investigations, outcomes and actions were clearly documented
•  All patients we spoke with during the inspection told us they felt safe in the care of the doctor and nurses at the practice
• The practice was clean and there was a nominated infection control lead
• The practice scored above the CCG average for the ease of making an appointment
• Patients we spoke with on the day and who left comment cards felt they were consulted and involved in their care, and were treated with dignity and respect
• Staff were complimentary about the availability to training; and the visibility and access to the partners

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

Importantly, the provider must:

• Put a system in place to disseminate learning from incidents, complaints, safety alerts and significant events to all staff and use such occurrences for risk assessment and quality improvement
• Ensure that recruitment processes are thorough, and include seeking references, proof of identity and, where appropriate, a criminal records check for new staff
• Complete the infection control audit and take action where appropriate
• Review the procedure for actioning test results to ensure they are promptly dealt with
• Provide staff with regular supervision and annual appraisal
• Ensure there is a governance framework to support the delivery of good care

In addition the provider should:

• Advertise to patients that they can request a chaperone if they wish for one
• Keep a log of prescription pad numbers
• Monitor the cleaning contract
• Update the business continuity plan
• Provide all new staff with an induction
• Provide regular team meetings and facilitate all staff attendance where possible
• Have a consistent vision for the practice and a strategy to deliver this
• Monitor medicines to ensure that they remain in date

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice