We carried out an announced focussed inspection at Bush Hill Park Trinity Surgery on 12 December 2019.
We previously inspected the practice in February 2016, when we rated the practice as Requires Improvement for providing safe, effective and well-led services. Included amongst the issues we identified, the practice could not provide sufficient evidence regular clinical audits were being conducted, a programme of regular in-house infection prevention and control audits had not been established and the practice did not have oxygen at its premises.
We subsequently carried out a focused inspection on 8 May 2017 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we had previously identified. At the inspection on 8 May 2017, we rated the practice good for providing safe and well led services and requires improvement for providing an effective service. We asked the practice to ensure the correct clinical pathways were being followed as current clinical pathways were not being adhered to. We rated the practice Good overall.
We carried out a further comprehensive inspection in June 2018, at which time we rated the practice good for providing a safe, caring, responsive and well led service and requires improvement for providing an effective service. The practice was rated as good overall. At the inspection we asked the practice to ensure all medical alerts were followed up, clinical pathways were being followed, to review the cold chain policy in respect of ensuring there was a backup thermometer for the fridge and to look at their rate of antibiotic prescribing as it was higher than the local average.
A further comprehensive inspection was undertaken in May 2019. We rated the practice good for providing a caring and responsive service and requires improvement for providing a safe, effective and well led service. The practice was rated requires improvement overall. We issued a requirement notice for Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment because we found that infection prevention and control policies had not been reviewed, areas of the practice were dirty and omitted from cleaning schedules, there was no record of the cleaning of hand-held medical equipment, actions from the recent infection prevention and control audit had not been followed up, there was no register of staff vaccines and emergency medicines were monitored inconsistently.
At the latest inspection in December 2019 we found that action had been taken to address all of these areas.
At this inspection, on 12 December 2019, 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.
We found that:
- Published child immunisation figures were below the minimum World Health Organisation target of 90%.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Review and update health and safety and premises risk assessments;
- Clarify who the infection and prevention control lead is when the nurse is absent;
- Review current nursing provision to ensure patient needs are met;
- Include the identification of members of staff who undertake the checking of medical devices and general cleaning schedules;
- Continue to look at ways to improve the prescribing rate;
- Continue to look at ways to improve outcomes for the childhood immunisation programme.
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