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Inspection carried out on 16 November 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Taverham Partnership on 12 April 2017. The overall rating for the practice was requires improvement, with requires improvement for providing safe, caring and well led services. The practice was rated as good for providing effective and responsive services. The full comprehensive report on the 12 April 2017 inspection can be found by selecting the ‘all reports’ link for the Taverham Partnership on our website at www.cqc.org.uk.

We undertook a focussed follow up inspection on 16 November 2017 to check they had followed their action plan and to confirm they now met legal requirements in relation to the breaches identified in our previous inspection on 12 April 2017. This report only covers our findings in relation to those requirements.

Overall the practice is now rated as good overall, and good for providing safe, caring and well led services.

Our key findings from this inspection were as follows:

  • There was a fire risk assessment and action plan in place.

  • The system for reporting, recording and learning from significant events had improved.

  • There was an infection prevention and control audit in place with associated action plan. The lead was trained for the role.

  • Staff had been provided with a forum for feedback and management were taking actions on identified issues. There was evidence of improved governance arrangements.

  • The standard operating procedures for the dispensary were detailed enough to assure safety.

  • Improvements had been made to the overall patient satisfaction outcomes on the GP patient survey, published in July 2017. The practice had recorded 75 patients as carers (approximately 0.7% of the practice list) and had thoroughly reviewed the system for identifying and offering carers support.

  • Electrical equipment was calibrated and tested appropriately.

  • The system for identifying patients and the coding of their medical records, particularly those with diabetes, had been reviewed. The staff were now using a system for the scanning and coding of letters to ensure patients records were coded correctly. The GPs were aware that poor coding was identified at our previous inspection. They had reviewed the patients with diabetes to ensure those- patients with diabetes that had been expected had been coded correctly.

  • The system for managing complaints had been improved. The practice monitored and recorded verbal complaints in order to identify any trends. The practice shared learning from complaints at meetings and we saw minutes of meetings to confirm this. The practice had a system in place to ensure the closure of complaints.

  • There was a child oxygen mask available in the emergency equipment.

The areas where the provider should make improvement are:

  • Continue to identify and offer support to carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 12 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Taverham Partnership on 12 April 2017. Overall the practice is rated as requires improvement.

This inspection was a follow up to our previous comprehensive inspection at the practice in October 2015 where breaches of regulation had been identified. The overall rating of the practice following the October 2015 inspection was good; however the practice was rated as requires improvement for providing safe services.

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

  • There was an effective system in place for reporting and recording clinical significant events. However, non-clinical significant events were not recorded.
  • Not all risks to patients were fully assessed; the practice had not conducted a fire risk assessment and electrical equipment testing was out of date.
  • Actions had not been completed from the infection control audit and the infection control lead was not trained to complete the role.
  • The standard operating procedures for the dispensary lacked sufficient detail to guide staff.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Not all hospital correspondence was read coded correctly.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice did not proactively offer support for carers and did not actively monitor the carers list.
  • 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 and easy to understand; however this information was not displayed in the waiting room. Improvements were made to the quality of care as a result of complaints and concerns. However, the practice did not record verbal complaints.
  • The majority of patients said they found it easy to make an appointment with a GP, with urgent appointments available the same day. However, some patients we spoke to were unsatisfied with the triage system in use at the practice.
  • There was a clear leadership structure, which was being further strengthened with the appointment of a nurse manager. However, not all the staff we spoke with felt supported to provide feedback. The practice sought feedback from patients and we saw examples of actions being taken in response to this feedback.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Ensure a fire risk assessment is undertaken and action taken in response to any risks identified.

  • Ensure there is an effective system in place to record all significant events, ensure actions are identified and learning is shared appropriately.

  • Ensure there is an effective system in place for assessing risks associated with infection control. Ensure the infection control lead is appropriately trained and supported to undertake this role.

  • Ensure staff are supported in their role. Implement and embed a system for staff to provide feedback.

The areas where the provider should make improvement are:

  • Review standard operating procedures for the dispensary to ensure they include sufficient guidance for staff.

  • Continue to identify carers and consider the need for health checks for this patient group.

  • Ensure that all electric equipment is tested or risk assessed and is safe to use in accordance with the practice policy.

  • Ensure hospital correspondence is consistently and appropriately read coded.

  • Monitor verbal, informal complaints in order to identify trends and share learning.

  • Undertake a formal risk assessment, identifying the risks and mitigation facts to ensure patients are not at risk of harm in the event of a child requiring oxygen in an emergency situation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 5 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Taverham Partnership on 5 October 2015. Overall the practice is rated as good.

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. 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 recruitment checks, infection control and the dispensary.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

  • 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 they found it easy to make an appointment with a GP and that 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 staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

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

Importantly the provider must

  • Ensure that all non-clinical staff who act as a chaperone have received training, are competent to perform the role and have had a risk assessment completed to determine whether a disclosure and barring service check is required.
  • Ensure that staff working in the dispensary complete appropriate training to demonstrate their knowledge and competence to undertake the role safely.
  • Complete an up to date legionella risk assessment to ensure the safe management of the water system in the building

The provider should also;

  • Have a clear plan in place to complete the full clinical audit cycles
  • Review the systems used to investigate significant events and complaints to ensure that learning is maximised and records are clear.
  • Check that cleaning records are maintained for quality monitoring purposes
  • Enhance infection control practice by improving the knowledge and skills of the infection control lead and ensuring that audit plans are actioned.
  • Implement regular controlled drugs audits, include near miss reporting in the dispensary and improve fridge temperature monitoring checks
  • Review the recruitment policy to ensure that current legislation around recruitment procedures are being followed.
  • Extend the current methods used to seek patient feedback about the service
  • The business continuity plan should include an up to date list of emergency contact numbers for staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone.