Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Writtle Surgery on 18 January 2017. The overall rating for the practice was good. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for The Writtle Surgery on our website at www.cqc.org.uk.

However, we rated the practice as requires improvement for providing safe services as we found medicines had not been stored in accordance with guidance. The fridge temperature had exceeded the recommended levels six times within three months. The dispensary staff had not recognised the significance of this and failed to follow cold chain procedure to ensure the medicines integrity.

This inspection was an announced focused inspection carried out on 24 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection 18 January 2017. 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 for the March inspection were as follows:

• We found the practice was storing medicines in accordance with guidance and cold chain procedures are followed.
• The practice had evidenced within their clinical meeting minutes their discussions of significant incidents and had scheduled the review of them to ensure learning had been embedded into practice.
• The practice medicine management lead was responsible for ensure the timely auctioning and consistent response to safety alerts.
• The practice was working with their patient participation group to educate patients on alternative methods of booking an appointment to reduce demand on the phone system and improve patient experience of the service.
• The nursing team lead on the inspection of emergency equipment and maintained records of checks conducted. These were overseen by the medicine management lead GP and the practice manager.

• The practice had reviewed their medicine management procedures to ensure they were reflective of practice.
• The dispensary staff conducted and maintained records of checks conducted for all their controlled drugs stock against their register, including the timely and safe destruction of controlled drugs.
• The practice was actively identifying and supporting patients with caring responsibilities. They had increased their number of carers by 34 patients to 88 patients, 1% of their patient list.

At this inspection we found that the medicines were being appropriately stored and monitored. Consequently, the practice is now rated as good for providing safe services.

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 Writtle Surgery on 18 January 2017. Overall the practice is rated as good.

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

• There was a system in place for reporting and recording significant events. Staff confirmed discussions had been held and lessons learnt. However, we found an absence of evidence to demonstrate how learning had been shared and changes embedded into practice.
• Patient safety and medicine alerts had been appropriately responded to.
• The practice was clean and tidy. However, we found medicines had not been stored in accordance with guidance and cold chain procedures followed.
• Records were not maintained of checks on emergency medicines or equipment to identify out of date or items due to expire.
• Medicine management procedures for the dispensary team were not reflective of practice and improvements were required in their management and destruction of controlled drugs.
• Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
• The practice actively engaged with their patients and families living with dementia. The practice staff had been trained as dementia friends to assist in identifying and supporting their patients better.
• The practice had identified 54 patients who had identified themselves as a carer amounting to 0.6% of their patient list.
• The practice understood and responded to the needs of their patients. For example referring to clinicians rooms by colour for patients with poor literacy skills and redecorating their waiting area to be dementia friendly.
• Information about how to complain was available and easy to understand. Complaints were responded to at the time of reporting where possible. Learning from complaints was shared with staff.
• The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
• There was a clear leadership structure and staff felt supported by management. The practice held regular staff, clinical and partner meetings.
• There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
• The practice proactively sought and valued feedback from staff and patients, which it acted on. The patient participation group was active.

We saw one area of outstanding practice:

The practice actively engaged with their patients and families living with dementia. They supported their patient participation group (PPG) to hold monthly dementia parties at the local hall; a practice nurse attended and answered questions from patients and carers. The PPG invited specialist speakers for example from respite holiday groups.

The practice staff had been trained as dementia friends to assist in identifying and supporting their patients better. They had redecorated their waiting area to be dementia friendly. They had enhanced the lighting of the waiting area and purchased lighter chairs to assist patients in differentiating between items to put them at ease. They had displayed pictures and clearer signage for patients.

Patients and their family members were offered longer appointments to discuss concerns. Carers were coded on their patient record systems and offered appropriate vaccinations and health checks. The practice held monthly dementia clinics facilitated by the Alzheimer’s and dementia support worker and provided 40 minute appointments. All patients with dementia were written to and informed of the range of services provided at the practice. The practice provided home visits for those unable to attend but who had expressed an interest. Practice nurses attended satellite sites to provide dementia care to patients.

The area where the provider must make improvements:

• Ensure medicines requiring refrigeration are stored in accordance with guidance and cold chain procedures are followed.

The areas where the provider should make improvement are:

• Evidence discussions held relating to significant incidents and how changes have been embedded into practice.
• Employing a consistent approach to ensure the timely and appropriate management of safety alerts.
• Addresses poor patient experience of trying to get through to this practice by phone.
• Maintain records of checks on emergency medicines or equipment to identify out of date or items due to expire.
• Ensure medicine management procedures for the dispensary team are reflective of practice.
• Ensure regular checks are conducted and recorded for all their controlled drugs stock against their register, including the timely and safe destruction of controlled drugs.
• Identify more patients with caring responsibilities.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We found people received individualised care and treatment that was planned and agreed with them. Health files were detailed and showed people received continuity of care between professionals and specialist services. The surgery was clean and tidy and had systems in place to manage and monitor the prevention and control of infection. Staff did not receive individual supervision but did attend clinical meetings and receive regular appraisals. Staff were provided with the opportunity to attend training and development relevant to their role and responsibilities. Staff told us they enjoyed their work and felt supported and valued by the provider.

People we spoke to told us "Doctors are very good, friendly and easy to talk to.” People found it easy to get an appointment by either phoning the surgery or attending in person. People told us that the staff listened and spent time with them, supporting them with the choices they made.