You are here

Inspection Summary


Overall summary & rating

Good

Updated 19 July 2019

This service is rated as Good overall. (Previous inspection – January 2018- not rated)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive at Basuto Medical Centre as part of our inspection programme.

There were no breaches of legal requirements at the last inspection. However, some recommendations were made which were all addressed promptly following the inspection.

Basuto Medical Centre is an independent private GP practice founded by the principle GP in 1990. The service provides primary medical services to fee paying patients. Access to the service is either on a ‘pay as you use’ basis or by an annual subscription plan which includes a set number of consultations per year.

The principal doctor at the practice is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was positive feedback from patients who use the service. We received 16 completed comment cards. Comments were all positive and included feedback about the ‘excellent’ service, helpful, caring and dedicated staff and thorough care received.

Our key findings were:

  • There was an effective system for reporting and recording significant events. The service had systems in place to identify, investigate and learn from incidents relating to the safety of patients and staff members.

  • Staff had received appropriate training according to their role.
  • Patient feedback about reception staff and clinical staff was positive.
  • Complaints had been dealt with in line with the regulations.
  • Care and treatment was provided in a modern, clean and well organised environment.

  • There were systems, processes and practices in place to safeguard patients from abuse.
  • The service had processes in place to securely share relevant information with others such as the patient’s GP and private healthcare providers.

The areas where the provider should make improvements are:

  • Continue with the planned programme of refurbishment to ensuring the treatment room areas meet infection control best practice.
  • Review systems to monitor the ambient temperatures of where medicines are stored to ensure they are stored within manufacturers guidelines.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 19 July 2019

We rated safe as Good because:

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction. The service had systems to safeguard children and vulnerable adults from abuse. Staff had received safeguarding training to level three.
  • The service had systems in place to assure that an adult accompanying a child had parental authority. At the last inspection, it was identified that arrangements should be in place to check the identity of new patients joining the practice. At this inspection, we found the new patient process had been amended to ensure this information as obtained and checked.
  • The service worked to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • We checked three staff files. The provider had carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.
  • Water checks were completed to reduce the risk of legionella occurring. (Legionella is a term for a bacterium, which can contaminate water systems in buildings).
  • There was an effective system and policies and procedures for infection and prevention control (IPC). We observed the premises to be visibly clean, daily cleaning schedules and systems for monitoring their effectiveness were in place. At the last inspection in January 2018, we observed that the storage of cleaning equipment did not comply with recommended guidance. Following the inspection, the issue was raised with the cleaning contractor and at this inspection equipment was appropriately stored.
  • We saw IPC audits, weekly room checks and monthly checks. These had identified the need for refurbishment of some of the flooring and taps in consultation rooms and clinical areas. This had started to be addressed with the replacement of carpet for washable flooring in one of the consultation rooms.
  • At the last inspection, the service was using a bench-top steriliser for the decontamination of reusable instruments. At this inspection, we saw that this equipment had been de commissioned and only single use equipment was used, in line with recommended guidance.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste. At the last inspection, it was identified that not all medicines were disposed of correctly. For example, hormonal injections. At this inspection we found that specific sharps bins for the disposal of such medicines had been obtained.

  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for staff tailored to their role.
  • The service had an automated external defibrillator (AED) and an oxygen cylinder for use in a medical emergency. Paediatric defibrillator pads and nebuliser masks were available.
  • Emergency medicines were easily accessible to staff in a secure area of the practice and all staff knew of their location. Checks to ensure emergency equipment was in working order and emergency medicines were in date and routinely undertaken. All the emergency medicines we checked were within their use by date.
  • There was an effective system for managing pathology tests and results processed through an independent clinical laboratory diagnostic service. Test results received were reviewed and actioned by clinicians on the same day. The service maintained a manual log of all tests sent to the laboratory and of results received, which allowed for the identification of any omissions.
  • A business continuity plan was in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff.
  • There was a system in place to ensure that adults accompanying child patients had the authority to do so.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. For example, guidance on what signs to look for was available at the front desk for staff and patients to refer to.
  • When reporting on medical emergencies, the guidance for emergency equipment is in the Resuscitation Council UK guidelines and the guidance on emergency medicines is in the British National Formulary (BNF).
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. For example, the patients GP and private healthcare providers were sent letters advising them of the outcome of the consultation.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading. The provider had plans to improve the storage of these records and had started to scan records onto the patients electronic records. Doctors notes were still written by hand and any referrals made by letter rather than template.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing. For example, the providers had completed an antibiotic audit to ensure prescribing was in line with national guidelines.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety. We saw examples where the GPs had alerted external agencies, including the General Medical Council where prescribing patterns of peers were not in line with safety guidelines.
  • The practice operated a dispensing service with a limited supply of medicines, which included analgesics (pain relief), antibiotics, anti-emetics and inhalers. There were no controlled medicines stocked. Dispensary medicines were stored in a secure area, in a locked cupboard with controlled access. There was no checks of the ambient temperatures to demonstrate medicines were stored at appropriate temperatures. The practice manager said this would be addressed. There were standard operating procedures in place for the ordering, prescribing, dispensing, storing and record management of dispensary medicines. The service, dispensed medicines in the manufacturer’s original packaging complete with the patient information leaflet. All medicines were dispensed with the appropriate label and by the prescribing GP.
  • The practice manager and a nominated receptionist undertook the stock management of medicines kept. A comprehensive record of internal dispensing was maintained, with monthly audits undertaken for the reconciliation of stock. A list was automatically generated of medicines requiring re-stock and orders placed with a local pharmacy.
  • Private prescriptions were generated from the electronic patient record system with the name and address of the practice and were signed by the prescribing GP before issue. Prescriptions issued were automatically on the patient’s electronic medical record.
  • There were two dedicated vaccine storage refrigerators with integral thermometers and each with a second thermometer independent of mains power. Records we reviewed demonstrated daily monitoring of the minimum, maximum and actual temperatures, with none falling outside the normal operating ranges for vaccine storage.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned, and improvements made

The service learned from and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety in the service. For example, a member of the public who was not registered at the practice had been injured outside of the practice and came into the practice to wash the injury and seek further advice. Because the patient was not registered at the practice and the practice was not registered to provide surgical procedures (stitches) they were advised to attend the nearest Accident and Emergency department. The complainant expressed concerns of feeling rejected by practice staff. The complaint records demonstrated duty of candour and showed that the incident had been investigated appropriately. Learning from the incident included ensuring that all similar incidents and patients would be reviewed by the GP even if the patient was not a practice patient.

  • The service acted on and learned from external safety events as well as patient and medicine safety alerts.

Effective

Good

Updated 19 July 2019

We rated effective as

Good

because:

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. For example, national sepsis guidance was used.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate and had access to pain relief which could be dispensed promptly.
  • GPs could offer palliative and end of life care but usually worked effectively with NHS GPs and healthcare professionals to ensure appropriate services were accessed. For example, the GPs encouraged NHS GP registration so that the patient could access the services of Macmillan nurses, occupational therapists and community nurses.

Monitoring care and treatment

The service was involved in quality improvement activity.

At the last inspection, it was suggested that audit activity be increased to demonstrate quality improvement. At this inspection, we saw that activity had been increased and used to make improvements and monitor the service. For example:

  • An antibiotic prescribing audit had been performed in June 2019 to ensure prescribing was set against NICE antibiotic stewardship guidelines. Patients who had been prescribed antibiotics between January 2017 and December 2018 were reviewed to ascertain whether there was a clinical indication and whether pathology had been requested. A total of 6483 prescriptions had been issued, representing 17% of the total prescriptions. A random sample of 30 cases were analysed which showed appropriate indications, conditions and investigations in 19 of the 30 cases. An action plan was agreed to change the policy and standard operating procedures for antibiotic prescribing and to re audit at the end of June (six months) to compare.
  • A referrals audit was completed between June 2017 and May 2018 and June 2018 and May 2019 to compare trends in referrals and ensure referrals were appropriate. The reaudit in 2018/19 showed a reduction from 1203 referrals to 703. A total of 30 referrals were selected at random which showed referrals had been appropriate. Trends in the referral specialities had also resulted in inviting consultants to present at educational sessions held at the practice.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical Council (GMC) and were up to date with revalidation. There were no nurses employed at the practice.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained.
  • The GPs attended regular education sessions at the practice. Consultants were invited to come to the practice to deliver educational talks. In the last year these had included: neurosurgeon, dermatologist, psychiatrist, paediatrician, orthopaedic surgeon, urologist, gastroenterologist, rheumatologist, cardiologist, care of the elderly consultant and a vascular surgeon.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, patients NHS GP and private healthcare providers.
  • Buddy systems were in place with the other doctors to monitor care and treatment and to check test results when doctors were on annual leave.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered NHS GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse. The provider had systems in place to report external services where prescribing patterns were not in line with national guidance. For example, we saw reports were made to the General Medical Council (GMC). We saw evidence of appropriate management of high risk medicines.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care. Patient comment cards showed that patients were involved in decisions made about their care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal NHS care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 19 July 2019

We rated caring as

Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. The 16 comments received from patients were all complimentary and contained feedback about the kind and caring staff.
  • Comments about care and treatment were also positive and referred to the ‘excellent’, ‘thorough’ and ‘clear’ service with ‘attention to detail’.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • Staff at the practice had been active in fund raising for local and national charities by holding cake sales and offering annual packages of care (memberships) as prizes in raffles.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language, although the practice manager added that all patients spoke English.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. Patients appreciated the standard 30 minute appointment times and added this gave them sufficient time to discuss any treatment and ask questions.

Privacy and Dignity

The service respected/did not respect patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 19 July 2019

We rated responsive as

Good

because:

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered. Consultation rooms and accessible toilet facilities were located on the ground floor of the premises. Breast-feeding and baby changing facilities were available as well as the provision of children’s books and toys in the waiting area.
  • Information about the practice, the services offered and financial costs, was provided on the practice website and at reception.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.
  • The service operated from 8am to 6.30pm Monday to Friday. Thirty-minute consultation appointments were available throughout the day with hour-long slots allocated for annual health checks. The service accommodated same day appointment requests where capacity permitted.
  • Out-of-hours arrangements were in place with a contracted provider.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 19 July 2019

We rated well-led as Good because:

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • The service was led by the principal GP supported by a small management team. The principal GP had developed and expanded the service over 28 years and had the skills, capacity and experience to deliver high quality sustainable care. The management team were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. For example, how to expand the business and hold more records and systems electronically.

  • Leaders and GPs at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • The service developed its vision, values and strategy jointly with staff and external partners.

  • Staff were aware of and understood the vision, values and strategy and their role in achieving them

  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. Staff were aware of the whistleblowing procedure.

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year.

  • There was a strong emphasis on the safety and well-being of all staff.

  • There were positive relationships between staff and teams. Staff said they enjoyed working at the practice and liked coming to work.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.

  • Staff were clear on their roles and accountabilities

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. We looked at the policies and found all but one had been reviewed. The out of date policy was reviewed by the end of the inspection.

  • There was a structured programme of meetings within the practice where complaints, clinical issues and significant events were discussed.

  • The practice manager saw the CQC inspection process as a positive event.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

  • The practice manager worked with another similar practice for benchmarking and sharing ideas and support.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, an ongoing internal survey was completed each year. The 2018 patient survey asked for feedback on access to appointments, staff, communication, the visit with the GP and overall satisfaction. The results of the 26 surveys were either excellent or very good. There were no poor responses. Suggestions included the introduction of a water cooler which was in the process of being introduced and a suggestion of Saturday morning and evening appointments which were being considered. A further suggestion to use the email or text system for appointment reminders was not possible due to the IT system used but was being considered along with a new IT system.

  • Staff said they could give feedback and usually did this informally as they worked together closely.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.