We carried out an announced comprehensive inspection at The Tinkers Lane Partnership on 10 December 2018 as part of our inspection programme.

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. We have rated then as good for the provision of safe, caring, responsive and well-led services, and as requires improvement for the provision of effective services. We rated the population groups; older people, families, children and young people, working age people (including 

those recently retired and students), people whose circumstances make 

them vulnerable, and people experiencing poor mental health (including people with dementia), as good. We rated the population groups: people with long-term conditions, and working age people (including those recently retired and students), as Requires Improvement.

We rated the practice as requires improvement for providing effective services because:

• When patients with one or more long term conditions failed to attend for an annual check up, the practice made a number of attempts to contact them. If this was unsuccessful, the practice “excepted” them. However, their was no evidence that a clinician had assessed some patients with increased risks prior to excepting them. We noted the practice overall exception reporting rate and some specific exception rates were higher than local and national averages. (Exception reporting is the removal of patients from quality outcome data where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects.) Whilst work was underway to reduce the exception reporting across all long term conditions, improvements were still required and it was too early to assess the impact at this inspection.

We also found that:

• There was clear evidence the practice had moved beyond the significant and critical challenges it has faced in the last few years, including the sudden loss of key staff, and a new forward-looking culture has been formed.
• 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.
• The practice delivered some services in partnership with other practices in the locality, such as services for older people and improved access to appointments.

The areas where the provider must make improvements are:

• Take action to ensure care and treatment is provided in a safe way for service users.

In addition, the provider should:

• Take action to ensure learning points from significant events and complaints were shared with all staff, including those unable to attend meetings where they were discussed.
• Take action to ensure medicines (other than those stored in a fridge and emergency medicines), are kept in an orderly manner to ensure older medicines are used first.
• Review their policy on staff references and ensure all references meet the standards set out in recognised guidance.
• Take steps to develop a written succession plan for key staff.
• Continue to take action to meet the national target of 80% of eligible women attending for cervical cancer screening.

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

We carried out an announced follow up inspection at Tinkers Lane Surgery on 15 December 2015. We carried out this inspection to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.

Our previous inspection in March 2015 found breaches of regulations relating to the safe delivery of services. There were also concerns relating to all domains. The overall rating of the practice in March 2015 was requires improvement. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance. At the inspection in December 2015, we found the practice had made significant improvements since our last inspection in March 2015 and that they were meeting all of the regulations which had previously been breached.

Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• Patients said it was not always easy to make an appointment with a named GP and it was hard to make an appointment with a female GP.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 areas where the provider should make improvement are:

• Ensure staff are aware of the requirements of the Duty of Candour.
• Ensure they have an adequate number of male and female GPs to meet patient’s needs.
• Ensure they carry out DBS checks for all nursing staff and review their DBS policy so it is in line with the latest guidance.

• Review their procedures for the audit and security of prescription pads.

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 Tinkers Lane Surgery on 23 March 2015. Overall the practice is rated as REQUIRES IMPROVEMENT.

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

• Urgent appointments were usually available on the day they were requested. However, patients said there were waits of up to two weeks for non-urgent appointments, there was difficulty getting through to the practice when phoning to make an appointment and waits of up to 40 minutes after appointment times.

• Few clinical audits had been carried out. There was limited evidence to demonstrate that audits were driving performance to improve patient outcomes.

• Data showed patient outcomes for March 2015 demonstrated an improvement from 2013/14 which had been overall below average for the local Clinical Commissioning Group.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

• Risks to patients were assessed and well managed, with the exception of those relating to some recruitment checks.

• 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.

• The surgery has worked with Carers Support Wiltshire in recent years, obtaining their Gold Award, followed by Gold Plus and this year was working to achieving the new ‘Gold’ award. The practice held two to three carers’ clinics a year and carers' events twice a year.

• A number of staff were ‘dementia friends’ and there were plans for more staff to undertake the training.

Importantly, the provider MUST:

• Ensure accurate records of staff training are maintained
• Maintain accurate records of all meetings regarding patient care and treatment.
• Ensure patient access to appointments and prescription services are improved and maintained.
• Ensure policies, procedures and guidance are updated to enable staff to carry out their role.
• Ensure there is an effective system for monitoring patients prescribed high risk medicines.
• Ensure all safeguarding measures are in place to protect patients at risk. Including safeguarding meetings, training and policy and procedure.

In addition the provider SHOULD:

      • Ensure the plan to undertake staff appraisal is implemented.

      • Develop processes to enable management to lead through learning

      • Develop and monitor processes for demonstrating the achievement of quality care standards for the  management of common long term conditions.

      • Ensure there are risk assessments for emergency medicines not held in the practice.

      • Develop an audit schedule to ensure clinical audit is carried out regularly.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We last inspected Tinkers Lane Surgery in September 2013. We found the practice was not meeting three of the essential standards of quality and safety. The practice had not made appropriate arrangements to ensure patients were protected from the risk of abuse, that infection control guidance was followed and there were processes for the safe management of medicines.

On the 18 December 2013 we undertook a further inspection of Tinkers Lane Surgery. We found the practice had developed systems and processes which ensured the three essential standards of quality and safety had been met. We reviewed processes and records relating to safeguarding, infection control and the management of medicines. We spoke with the acting practice manager, infection control lead and six members of staff.

Patients were protected from the risk of infection because the practice had systems in place to manage the risks. We found that staff had received infection control training, a comprehensive audit had been undertaken and appropriate cleaning schedules and monitoring was in place.

The practice had and effective system to protect patients from the risk of abuse. Staff had received safeguarding training and had been given safeguarding policies. A whistle blowing policy had also been developed and shared with all staff.

Medicines were stored safely and in line with medicines management guidance by the Department of Health and Royal Pharmaceutical Society. We found appropriate medicines management policies and medication checks were undertaken.

Patients who used the service were treated with respect and involved in making decisions about their care and treatment. One patient told us “The reception staff are very friendly and welcoming. They treat me with respect and are always very professional”.

We spoke with six patients who attended the practice the day of our inspection. All of the patients were complimentary about the staff and GP services the practice provided. One person said "The practice is very good. I have been a patient here for 82 years and I feel very safe with the staff".

Patients were not always cared for in an environment that was hygienic and cleanliness was not monitored appropriately. However, patients we spoke with told us that the practice was always clean and tidy.

Patients received appropriate medication reviews. We found that the handling and storage of medications was not always in line with current medicines management guidance.

Patients were asked for their feedback about the service and the practice responded and took action where appropriate.