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Inspection Summary


Overall summary & rating

Good

Updated 27 March 2017

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Capelfield Surgery on 21 January 2016. The overall rating for the practice was good, but breaches of legal requirements were found in the safe domain. The practice sent to us an action plan detailing what they would do in relation to the shortfalls identified and the action taken in order to meet the legal requirements in relation to the following:-

  • The practice did not have a system for production of Patient Specific Directions to enable Health Care Assistants to administer vaccinations after specific training when a doctor or nurse were on the premises.
  • Clinical specimens were seen to be stored in the same fridge as medicines which does not comply with the Public Health England Protocol for ordering, storing and handling vaccines.
  • Printer prescription paper was not monitored within the practice and large quantities of prescription paper were observed left in printers with the rooms left unlocked.
  • The practice was unable to provide evidence that an evacuation drill had been carried out.
  • There was a wall mounted mercury sphygmomanometer, an instrument used for measuring blood pressure, in one room but there was no mercury spill kit on site.
  • The practice could not provide proof that all clinicians had received Mental Capacity Act (MCA) and deprivation of liberties (DoLs) training.

The full comprehensive report on the 21 January 2016 inspection can be found by selecting the ‘all reports’ link for Capelfield Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 March 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 21 January 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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

  • The practice now had a system in place for the production of Patient Specific Directions.
  • The practice no longer stored specimens in the vaccine fridge.
  • Printer prescription paper was now stored in a locked cupboard and a system for monitoring it throughout the practice introduced.
  • A fire evacuation drill had been carried out and recorded.
  • The mercury containing instrument had been removed.
  • All clinical staff had received Mental Capacity Act and Deprivation of Liberty training.

Additionally we saw that:

  • Staff had been trained in adult safeguarding and basic life support.
  • The practice had a recruitment policy in place, but had not employed any new staff since the previous inspection.
  • However the procedure for registering a new manager and the regulated activity ‘maternity and midwifery’ had not yet been completed.

The areas where the provider should make improvement are to:

  • Ensure that the process to register a manager with CQC is completed.
  • Ensure that all regulated activities being provided are registered with CQC including maternity and midwifery.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 27 March 2017

At this inspection we found that safety systems and procedures had improved and the practice were no longer in breach of the legal requirements. The practice now had a system in place for the production of Patient Specific Directions. They had also made changes in their arrangements with respect to specimens and no longer stored specimens in the vaccine fridge. Processes had been put in place to ensure that printer prescription paper was now stored in a locked cupboard and a system for monitoring it throughout the practice introduced. A fire evacuation drill had recently been carried out and recorded and there were no longer any mercury containing instruments in the practice. We saw that all clinical staff had received Mental Capacity Act and Deprivation of Liberty training.

Other improvements that had been made were that staff had been trained in adult safeguarding and basic life support. Also the practice had a recruitment policy in place, but had not employed any new staff since the previous inspection.

Effective

Good

Updated 27 April 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average for the locality and compared to the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 27 April 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 27 April 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Patients said they could make an appointment with a GP and there were urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 27 April 2016

The practice is rated as good for being well-led.

  • 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 this.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance 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 provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a focus on learning and improvement at all levels.
Checks on specific services

Older people

Good

Updated 27 April 2016

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

People with long term conditions

Good

Updated 27 April 2016

The practice is rated as good for the care of people with long-term conditions.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • 87.8% of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less which was better than the national average of 78%.
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 27 April 2016

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
  • 78.6% of patients with asthma, on the asthma register, have had an asthma review in the preceding 12 months which was comparable to the national average of 75.4%.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • The practice’s uptake for the cervical screening programme was 83.1% which was slightly above the national average of 81.8%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice was able to provide us with data that showed they were achieving 96-98% of the target for initial immunisations and 89-97% for booster immunisations.

Working age people (including those recently retired and students)

Good

Updated 27 April 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.
  • The practice offered extended hours appointments between 9am – 12pm every Saturday morning for patients who find it difficult to attend during normal surgery opening times.

People whose circumstances may make them vulnerable

Good

Updated 27 April 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless patients, travellers and those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

People experiencing poor mental health (including people with dementia)

Good

Updated 27 April 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • 92.1% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is above the national average of 84%.
  • 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record, in the preceding 12 months which was better than the national average of 88.5%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.