Dr WA Cotter + Dr JCJM Bohmer -Laubis Also known as Bellegrove Surgery

We carried out an inspection of Dr WA Cotter + Dr JCJM Bohmer -Laubis on 2 December 2019 to follow up concerns identified at our last inspection undertaken on 22 February 2019.

At that inspection we identified concerns around the monitoring of patients on one high risk medicine. The practice had also failed to ensure that appropriate recruitment checks were undertaken when employing staff and that all training had been completed including chaperone training. As a result, the practice was rated as inadequate for safe and requires improvement for being well led which resulted in the service being rated as requires improvement overall. We issued a requirement notice for regulation 12; safe care and treatment and regulation 17; good governance. We also recommended that the provider should undertake fire drills, implement a system for tracking and monitoring safety alerts, improve the identification of carers and support offered to them and establish a schedule of staff meetings.

At this inspection we found that the provider had put systems in place to ensure that patients prescribed high-risk medicines were receiving regular monitoring in line with guidance and that all staff whose files we reviewed had completed the required training and that recruitment checks had been completed for all newly recruited staff. The practice had also taken action to address some of the actions we recommended the provider should take. However, we found that the practice still needed to undertake further work to improve the identification of carers.

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 and good for all population groups.

We rated the practice as good for providing safe services because:

• The systems in place for managing patients prescribed medicines, including high risk medicines, ensured adherence to guidance and that patients remained safe.
• The practice had safeguarding systems in place.
• There were systems in place to report significant events and we saw evidence of discussion of events in practice meetings and changes made
• Appropriate recruitment checks had been completed for staff employed at the service.
• Risks associated with the premises had been assessed however some of actions suggested to mitigate low level risks had not been implemented.
• The provider had adequate arrangements in place to respond to emergencies including patients who presented with symptoms of sepsis.

We rated the practice as good for providing effective services because:

• There was evidence of quality improvement activity.
• Staff were receiving regular appraisals.
• Effective joint working was in place.
• Patients were receiving regular reviews and the treatment provided was in line with current guidelines this was reflected in high levels of achievement against most local and national targets. However, performance against targets for some childhood immunisations were below the World Health Organisation Targets, performance for cervical screening was below the Public Health England target and the proportion of patients with serious mental illness who received an annual review was slightly below the local and national average. The practice provided us with unverified data which suggested uptake for childhood immunisations was higher than the published figures and provided action plans for how to improve on targets related to cervical screening and mental health reviews.

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patient feedback was almost exclusively positive about the quality of care provided by both clinical and non-clinical staff

We rated the practice as good for responsive services because:

• Complaints were managed in a timely fashion and detailed responses were provided.
• Feedback from both the national GP patient survey, patients and comment cards received by CQC was positive regarding access care and treatment at the practice. Patient survey feedback was more positive than average local and national survey scores.

We rated the practice as good for providing well-led services because:

• There were effective governance arrangements.
• The provider had adequate systems in place to assess, monitor and address risk in most areas although some low-level risks related to the premises had not been addressed.
• The provider had an active patient participation group who met regularly and felt able to raise concerns and contribute ideas regarding the operation of the service. We saw evidence that the provider considered suggestions.
• There was evidence of continuous improvement or innovation.
• Staff provided positive feedback about working at the practice which indicated that there was a good working culture.

The areas where the provider should make improvements are:

• Implement all recommendations from premises risk assessments in a timely fashion or put in place mitigating action where recommendations cannot be fully implemented.
• Continue with work to improve on national cervical screening, immunisation, mental health targets and review areas with above average exception reporting.
• The practice should improve the identification of carers to enable this group of patients to access the care and support they need.
• Have all staff complete equality and diversity training.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

We carried out an announced comprehensive inspection at Bellegrove Surgery 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.

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients were able to access timely and effective care and treatment.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Staff recruitment records were incomplete.
• The practice did not have appropriate systems in place for the management of one particular high risk medicine.

We rated the practice as requires improvement for providing well-led services because:

• The overall governance arrangements were ineffective.
• The practice did not always have clear and effective processes for managing risks.

We rated the practice as good for providing effective, caring and responsive services because:

• 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 practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• The practice should ensure that fire drills are carried out in order to adhere to all fire regulations.
• The practice should ensure that an effective system of tracking and monitoring safety alerts is implemented.
• The practice should improve the identification of carers to enable this group of patients to access the care and support they need.

• The practice should establish a schedule of formal staff meetings.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care