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Inspection carried out on 26/11/2019

During a routine inspection

We carried out an announced comprehensive inspection at North Brink Surgery on 26 November 2019. At this inspection we followed up on a breach of regulation identified at a previous inspection on 20 October 2018. We had served a requirement notice for regulation 12 safe care and treatment. The full comprehensive report from the October 2018 inspection can be found by selecting the ‘all reports’ link for North Brink Surgery on our website at www.cqc.org.uk.

At the previous inspection in 20 October 2018 we rated the practice as requires improvement overall as we rated the service as requires improvement for providing safe and responsive because:

  • There were no effective systems to review the process for prescribing antibiotics and controlled medicines.
  • There was an insufficient appraisal system.
  • Patients with long term conditions did not always receive a review in a timely manner.
  • Not all recommended emergency medicines were available in the practice.
  • The process for acting on safety alerts was inconsistent.

These areas affected all population groups, and the practice was rated as requires improvement in all population groups.

At our November 2019 inspection we have rated the practice as good overall and all the population groups as good. We have rated the practice as outstanding for providing well led services.

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 found that:

  • The practice demonstrated outstanding leadership as senior clinicians and all staff worked in a clear and cohesive patient centre approach to providing primary care to their patients.
  • The practice ensured they protected patients and staff by providing comprehensive safety systems to meet the challenges of providing services from a listed building.
  • The practice had developed a clinical model which overcame the challenge of not recruiting more GPs. This model of care which comprised of 17 nursing staff and two pharmacists required cohesive team work and robust governance systems.
  • They developed this model by working with patients to seek their views and feedback to ensure they delivered high quality, accessible health care.
  • Through the development of the wider skill mix they told us they had a truly holistic approach to assessing, planning and delivering care and treatment to all patients who used the services.
  • There was a strong person centred and open culture in which safety concerns raised by staff and patients was highly valued as being integral to learning and improvement.
  • Patients were supported, treated with dignity and respect and were involved partners in their care.

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

  • The leadership had ensured the practice was able to deliver high quality care and treatment to patients despite the challenge of a scarcity of GPs and a consequent inability to recruit into vacancies. They had developed and implemented an innovative model of care which centred on using a diverse skill mix of clinical staff. They consistently reviewed this and had sustained and further improved patient satisfaction. The practice demonstrated effective governance systems and processes and the open culture was used to drive and improve the delivery of high-quality person-centred care.

The areas where the practice should make improvements are:

  • Review and improve the recall system for patients to ensure they receive regular monitoring of blood pressure for patients with hypertension.
  • Continue to monitor the prescribing of antibiotics to ensure safe prescribing of medicines.
  • Review the safeguarding training of all non-clinical staff and where appropriate ensure they receive safeguarding level two training.
  • Continue to review and improve uptake of childhood immunisations to meet the WHO target of 95%.
  • Continue to improve uptake of patients who are eligible to attend cancer screening appointments.
  • Review and improve the uptake of the annual reviews for patients with learning disabilities.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 20 November 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating June 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

We carried out an announced comprehensive inspection at North Brink Practice on 20 November 2018. We inspected the practice as part of our inspection programme.

At this inspection we found:

  • The practice was proactive in identifying significant events. Ninety significant events had been recorded in the last 12 months. When incidents happened, the practice reviewed and analysed the incidents to ensure they learned from them and improved their processes.
  • The practice did not have an effective system in place for responding to safety alerts. Data from the quality and outcome framework 2017/2018 showed the practice performance on some indicators was below the local and national averages. For example, some indicators for the management of long term conditions such as diabetes and hypertension were below the CCG and national averages. We noted the practice’s exception reporting rate was lower than the local and national averages.
  • The practice had not reviewed and risk assessed the availability of emergency medicines for example the use of atropine for the treatment of bradycardia, as a possible complication of intrauterine device insertion. The practice took immediate action and reviewed this on the day of the inspection and told us they had ordered other medicines for delivery the next day.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice had evidence of quality improvement with completed repeat cycle audits.
  • The practice provided the extended access service for patients from all four practices in Wisbech and supported the minor injuries unit at the local hospital.
  • The practice provided staff with some ongoing support. There was an induction programme for new staff. Support included one to one meetings, coaching and mentoring, clinical supervision and revalidation, however some staff had not received appraisals in the last 12 months.
  • The GP patient survey dated July 2018 showed that patient satisfaction for access to the practice was lower than the CCG and national averages.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Review the process for prescribing antibiotics and controlled drugs to ensure that the prescribing is effective.
  • Continue to proactively identify carers on the practice patient list to ensure they are offered appropriate care and support.
  • Review and monitor the systems in place to ensure all patients with long term conditions receive the appropriate follow up within a timely manner.
  • Review and monitor poor patient satisfaction in relation to telephone access and access to a preferred GP.
  • Review the appraisals system to ensure all members of staff receive an appropriate review.
  • Review and monitor the risk assessment to ensure that appropriate emergency medicines are available in the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

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

Inspection carried out on 23 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at North Brink practice on 23 June 2015. The overall rating for this practice is good. We found the practice to be good for providing safe, effective, caring, responsive and well-led services. The quality of care experienced by older people, by people with long term conditions and by families, children and young people is good. Working age people, those in vulnerable circumstances and people experiencing poor mental health also receive good quality care.

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

  • The practice was a friendly, caring and responsive practice that addressed patients’ needs and that worked in partnership with other health and social care services to deliver individualised care.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Risks to patients were assessed and well managed.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Staff were supervised and supported and any further training needs had been identified and planned for.
  • There was a clear leadership structure and staff felt supported by management.

We saw two areas of outstanding practice:

  • The practice provided a same day clinic operated by four nurses supervised by a GP. This had increased the number of patients that could be seen at an on the day appointment to 500 a week. The practice had set a target to increase this to 750 per week.
  • The practice had a well embedded learning culture for staff through the provision of internal and external training as well as an annual training budget the equivalent of two weeks wages per year. The practice linked specialised training in, for example, chronic diseases for nursing staff to an increase in basic salary. Staff reported that they felt well supported to develop and improve their skillset.

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

Importantly the provider should :

  • Ensure all staff complete training deemed mandatory by the practice, for example basic life support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice