Archived: Bursledon Surgery

Letter from the Chief Inspector of General Practice

On 20 June 2016 we carried out a comprehensive inspection at Bursledon Surgery. Overall the practice was rated as inadequate and placed in special measures for a period of six months. The practice was found to be inadequate in safe, effective, responsive and well led, and requires improvement in caring.

As a result of that inspection we issued the practice with warning notices in relation to the safety and governance at the practice.

The issues of concern related to the safe domain and included:

• shortfalls in significant event reporting and sharing of learning;
• safe handling of medicines and prescriptions;
• shortfalls in infection control processes;
• shortfalls in managing medicines and healthcare products;
• regulatory agency alerts and safeguarding arrangements.

The issues of concern related to the well led domain included:

• a lack of formal governance arrangements and systems for assessing, monitoring and mitigating risks.
• There were limited quality assurance processes in place to demonstrate that service provision was monitored and improved where needed.

At the inspection in June 2016 we also made requirement notices regarding: staff levels; provision of staff training and appraisals; and appropriate checks being carried out prior to a member of staff commencing employment.

We then carried out a focused inspection of the practice on 6 December 2016 to establish whether the requirements of the warning notices had been met. We found improvements had been made but further work was needed to ensure there were suitable procedures in place to manage business resilience and continuity when needed, for example in the event of a power failure to the practice. The practice was issued with a requirement notice for improvement to ensure it had a business continuity and resilience plan in place.

We carried out an announced comprehensive inspection at Bursledon Surgery on 20 April 2017 to assess compliance with the requirements and also to ensure changes made as a result of the warning notices were embedded.

The practice was found to be good in safe, effective, caring, responsive and requires improvement in well led.

Overall the practice is now rated as good.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• There was a system in place for reporting and recording significant events. Monitoring of actions recommended following a significant event was not consistent and the practice could not demonstrate fully that learning had been shared with relevant members of staff.
• Staff were aware of current evidence based guidance.
• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns, but learning was not consistently shared with relevant staff and actions were not monitored.
• Patients we spoke with said they found it easy to make an appointment with a named GP and 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 leadership structure and staff usually felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.

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

Importantly, the provider must:

• Ensure governance arrangements are demonstrate a clear oversight of service provision, such as ensuring all staff receive suitable training on the Mental Capacity Act 2005 and are able to apply it according to their role.

In addition the provider should:

• Review arrangements to make sure all patient group directives are authorised and signed by relevant staff.
• Review arrangements to ensure a comprehensive understanding of the performance of the practice is maintained and ensure that learning has been shared with relevant staff and actions taken are monitored
• Continue with remedial works needed as a result of the Legionella risk assessment.
• Review equipment provided for patient use, in particular chairs and baby changing facilities.
• Review arrangements for providing translation services when a patient is accompanied by a family member.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

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 inspection at Bursledon Surgery on 6 December 2016 to monitor whether the registered provider had met the requirements of the warning notices which were served following an announced comprehensive inspection in June 2016. The timescale given to meet the requirements was 31 October 2016. The provider submitted an action plan to demonstrate how they would become compliant with the regulations.

Two warning notices were served which related to regulations 12 Safe care and treatment and 17 Good governance of the Health and Social Care Act 2008.

Areas which did not meet the regulations in June 2016 were:

• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff. When incidents and complaints had been identified reviews and investigations were not thorough enough.

• The system in place for reporting, recording and monitoring significant events was not always followed. There was no structure for identifying, reporting and analysing incidents in order to learn from them and prevent them from happening again.

• There were no processes in place for receiving and responding to medicines alerts from the Medicines and Healthcare products Regulatory Agency.

• Staff had not received training which was relevant to their roles, this included safeguarding adults and children; infection control; chaperone training and basic life support.

• Staff were not clear whether there was a safeguarding policy in place and staff did not know if there was a whistle blowing policy at the practice.

• The practice was unable to demonstrate that staff who chaperoned had a Disclosure and Barring Service check or a risk assessment, to ensure they were competent and suitable to carry out this role.

• Medicines which had been opened were not dated to ensure they were not used past their expiry date.

• Patient Group Directions which had been adopted by the practice to allow nurses to administer medicines in line with legislation were out of date.

• The infection control policy was not up to date and current. The last annual infection control audit had been carried out in May 2015 and there was no record of action taken to address any improvements which may have been necessary.

• There was a lack of clarity on what duties staff and medical students were expected to perform and how they would be supported, supervised and mentored in this.

• Governance arrangements to ensure that there were sufficient numbers of staff employed and were supported to carry out their duties were not effective.

• Accurate and complete records of patient care and treatment were not consistently maintained.

• The systems for ensuring that clinical coding of patient notes had been completed were not implemented well enough to ensure that all information was captured accurately.

• The practice was unable to demonstrate how the practice aimed to improve the care of all patients with long term conditions.

• There were no process in place for staff meetings, appraisals and clinical supervision.

• Staff had limited opportunities to provide feedback on the service provided; there were no clear plans in place on how the practice would develop in the future.

Key findings of the inspection 6 December 2016:

• Systems in place to assess the risks to the health and safety of patients receiving care and treatment had improved in most areas. However, further work was needed to ensure that there is a clear policy for staff to know what is to be included as a significant event.

• Processes in place for Medicines and Healthcare products Regulatory Agency alerts now demonstrated that these were handled appropriately and cascaded to staff for action when needed.

• All staff had received training on safeguarding adults and children; infection control; basic life support; and chaperone training, which was recorded. Suitable arrangements were in place to show that staff that chaperoned had been appropriately checked.

• Medicines were managed in line with current guidance and there were safe systems in place to monitor expiry dates, stock levels and storage.

• Patient Group Directions which had been adopted by the practice to allow nurses to administer medicines in line with legislation were in date.

• Infection control policies and procedures were up to date and contained relevant information. The practice had carried out an infection control audit and made improvements where needed. A planned programme of audits was in place.

• Governance arrangements had been improved and there were clear roles and responsibilities for all staff. All practice policies and procedures were in the process of being reviewed.

• All staff had received an appraisal; and there were arrangements in place to provide clinical supervision and monitoring for staff as needed.

• Patients’ records were maintained and contained sufficient information on care and treatment given. Staff had adequate time to complete tasks such as clinical coding and summarising of patient notes.

• The practice was able to demonstrate how it was reviewing and improving the care of patients with long term conditions.

• Minutes of meeting held showed that complaints, actions and outcomes were discussed with relevant staff members.

• Systems and processes in place had been reviewed and improved to provide opportunities for staff to feedback on service provision.

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

Importantly, the provider must:

• Monitor and improve the quality and safety of the services with regard to business resilience and continuity.

The provider should:

• Continue to manage and mitigate risks to the health and safety of service users with regard to significant events and staff are aware of what the practice considers to be a reportable significant event.

The Care Quality Commission has found that improvements have been made and the warning notices are met.

The full report published on 20 October 2016 should be read in conjunction with this report. The practice remains in special measures until a full comprehensive inspection is carried out by the Care Quality Commission. Therefore the overall rating remains inadequate.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice