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The Randolph Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 August 2018

This practice is rated as requires improvement overall.

(At the previous inspection in December 2014 the practice was rated as good overall).

The key questions are rated as:

Are services safe? - Good

Are services effective? - Requires improvement

Are services caring? - Requires improvement

Are services responsive? - Requires improvement

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at The Randolph Surgery on 12 July 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether The Randolph Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • There was a lack of local clinical leadership and governance.
  • Risks to patients were assessed and well managed in some areas, with the exception of those relating to calibration of medical equipment, childhood immunisations and management of blank prescription forms.
  • There was limited evidence of quality improvement activity in some areas to review the effectiveness and appropriateness of the care provided.
  • According to unverified and unpublished data there was a significant reduction in the Quality Outcomes Framework (QOF) results for the year 2017/18 compared to the previously published QOF results for 2016/17.
  • The practice’s uptake of the national screening programme for breast cancer screening and childhood immunisations rates were below the national averages.
  • There were ineffective arrangements in place for planning and monitoring the number of staff needed to meet patients’ needs.
  • Patients feedback highlighted concerns about the appointment booking system, availability of appointments with the GPs and the continuity of care.
  • Feedback suggested that patients felt they were not always involved in making decisions about their care and treatment and they did not have sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff had received up to date training relevant to their role. Staff appraisals had been completed in a timely manner.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain were available and easy to understand.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • Staff we spoke with informed us the management was approachable but they reported lack of responsiveness and support from the head office, and they did not have confidence that their concerns would be addressed in a timely manner.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review the system in place to improve the management of blank prescription forms, to ensure this is in accordance with national guidance.
  • Review and improve the systems in place to effectively monitor care plans and health checks for patients with learning disabilities and patients experiencing poor mental health.
  • Review the system in place to promote the benefits of childhood immunisation and breast cancer screening in order to increase patient uptake.
  • Ensure information about a translation service is displayed in the reception area informing patients this service is available. Ensure information posters and leaflets are available in multiple languages.
  • Ensure written information is available for carers to enable them to access the support available via the external agencies.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 22 August 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for their role and had received a DBS check. (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.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • On the day of the inspection, the practice had arrangements to ensure that facilities and equipment were safe and in good working order. Although new clinical equipment was in place but we found that old clinical equipment was not calibrated since August 2016. However, old clinical equipment was removed and an appointment was booked to carry out calibration in July 2018.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis. Staff had completed formal sepsis awareness training. However, some non-clinical staff we spoke with were not sure how to identify symptoms of sepsis in an acutely unwell patient.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had systems for appropriate and safe handling of medicines.

The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.

  • The practice kept prescription stationery securely. On the day of the inspection, we saw there was a system in place to monitor the use of blank prescription forms for use in printers and handwritten pads but these were not correctly recorded and tracked through the practice at all times.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of high risk medicines and followed up on appropriately.

Track record on safety

The practice had a good track record on safety.

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

Lessons learned and improvements made

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There was an incident reporting policy for staff to follow and there were procedures in place for the reporting of incidents and significant events. No significant event was reported in the last 12 months but 19 incidents had been reported in the last 12 months. The practice had investigated the incidents, took appropriate action and maintained a comprehensive log.
  • The national patient safety and medicines alerts were systematically received and shared with the team.

Please refer to the Evidence Tables for further information.

Effective

Requires improvement

Updated 22 August 2018

We rated the practice as requires improvement for providing effective services overall and across all population groups.

The practice was rated as requires improvement for providing effective services because:

  • There was limited evidence of quality improvement activity to review the effectiveness and appropriateness of the care provided.
  • The practice had experienced a significant reduction in the QOF year 2017/18 (unverified QOF data) results compared to the previously published QOF results for 2016/17.
  • The practice’s uptake of the national screening programme for breast cancer screening and childhood immunisations rates were below the national averages.
  • The practice was required to review and improve the systems in place to effectively monitor care plans and health checks for patients with learning disabilities and patients experiencing poor mental health.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

This population group was rated as requires improvement for effective care.

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from the hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

This population group was rated as requires improvement for effective care.

  • Most patients with long-term conditions had received a routine annual review to check their health and medicines needs were being met.
  • For example, the practice had carried out a review of medicines reviews on 29 June 2018, which identified 69 patients (out of a total of 1207 patients) with long-term conditions who did not receive an annual medicine review in the last 12 months.
  • The practice had identified 41 patients on five or more repeat medicines who did not receive an annual medicine review in the last 12 months.
  • The practice had identified 13 patients on 10 or more repeat medicines who did not receive an annual medicine review in the last 12 months.
  • We saw the practice had developed an action plan to carry out medicines reviews by August 2018.
  • For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in the hospital or through out of hours services.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • In 2016-17, the practice’s performance on quality indicators for long term conditions was in line with the local and national averages. However, there was a significant reduction in the unverified Quality Outcomes Framework (QOF) data for 2017-18. Please refer to the Evidence Tables for further information.
  • The practice was aware of this shortfall and they had developed a comprehensive achievement plan for patients with long-term conditions with clear timescales to achieve most of the targets by October 2018 and some of the targets by March 2019.

Families, children and young people:

This population group was rated as requires improvement for effective care.

  • Childhood immunisations were not carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were not in line with the target percentage of 90% for three out of four immunisations measured (in 2016/17) for children under two years of age. The practice was aware of this shortfall and informed us they had developed an action plan to increase patient uptake.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

Working age people (including those recently retired and students):

This population group was rated as requires improvement for effective care.

  • The practice’s uptake for cervical screening was 57%, which was below the 72% coverage target for the national screening programme. The practice had taken steps to promote the benefits of cervical screening in order to increase patient uptake. The practice had advertised the relevant information on their website and displayed on the notice boards in the waiting area encouraging patients to take part in the national cancer screening programme. According to recent data (unverified) provided by the practice on the day of the inspection, the practice performance for the uptake for cervical screening was 63%. This was a 6% increase from the 2016/17 data (Public Health England).
  • The practices’ uptake for breast and bowel cancer screening was below the national average. In total 46% of patients eligible had undertaken bowel cancer screening and 55% of patients eligible had been screened for breast cancer, compared to the national averages of 55% and 70% respectively.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

This population group was rated as requires improvement for effective care.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

This population group was rated as requires improvement for effective care.

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • Health checks were offered and care plans were completed for patients with a learning disability and patients experiencing poor mental health. For example,
  • 7% (six out of 83) of patients experiencing poor mental health were involved in developing their care plan for this year.
  • 13% (two out of 15) of patients on the learning disability register were involved in developing their care plan for this year.

Monitoring care and treatment

The most recent published Quality Outcome Framework (QOF) results for the period 1 April 2016 to 31 March 2017 were 97% of the total number of points available compared with the clinical commissioning group (CCG) average of 90% and the national average of 96%. The overall clinical exception reporting rate was 12% compared with a national average of 10%. (QOF is a system intended to improve the quality of general practice and reward good practice. Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate).

The practice informed us they had achieved 65% (358) of the total number of points available (559) in the QOF year 2017/18 (unverified QOF data). This was a significant reduction from the previously published QOF results for 2016/17. Please refer to the Evidence Tables for further information.

The practice had carried out some quality improvement activity and reviewed the effectiveness and appropriateness of the care provided. However, improvements were required.

  • The practice had undertaken six clinical audits in the last two years. However, these audits were mostly limited to the prescribing issues and there was limited quality improvement activity to ensure effective monitoring and assessment of the quality of the service provided to patients with long term conditions.
  • The practice used information about care and treatment to make improvements. For example, the practice carried out an audit to find out whether antibiotic treatment guidelines for urinary tract infections were followed appropriately. Consultation notes were reviewed and compared with clinical guidelines. They found 63% of consultation notes were clearly documented to follow guidelines, while in other cases there were some complicating factors or the clinical guidelines were not followed appropriately. The practice shared the findings with the clinical staff and reminded to follow the current guidelines correctly. The practice had planned to carry out a follow up audit after six months in December 2018.
  • Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

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

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice 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. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from the hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

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

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

Please refer to the evidence tables for further information.

Caring

Requires improvement

Updated 22 August 2018

We rated the practice as

requires improvement

for caring.

The practice was rated as requires improvement for caring because:

  • Feedback suggested that patients felt they were not always involved in making decisions about their care and treatment and they did not have sufficient time during consultations to make an informed decision about the choice of treatment available to them.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was mostly positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • Comment cards highlighted that staff responded compassionately when patients needed help and provided support when required.
  • Two patients and a member of the patient participation group (PPG) we spoke with said staff were helpful, caring and treated them with dignity and respect.
  • We noted the NHS friends and family test (FFT) results for the last six months and 93% of patients were likely or extremely likely recommending this practice.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. However, improvements were required. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Results from the national GP patient survey (published in July 2017) showed patients responded negatively to questions regarding GPs and nurses about their involvement in planning and making decisions about their care and treatment and explaining tests and treatments.
  • As part of our inspection, we also asked for Care Quality Commission (CQC) comment cards to be completed by patients prior to our inspection. Seven of the 17 patient CQC comment cards we received were positive about the service experienced. Four of the 17 patient CQC comment cards we received were neutral and six were negative which raised concerns that patients felt rushed during the clinical consultations and GPs did not always listen to them appropriately. Some patients highlighted dissatisfaction about the service provided by the reception staff.
  • Interpretation services were available for patients who did not have English as a first language. However, we did not see notices in the reception area, including in languages other than English, informing patients this service was available.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • The practice identified carers and supported them. However, on the day of the inspection, we did not see any notices or leaflets available for carers to find further information and access community and advocacy services.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Requires improvement

Updated 22 August 2018

We rated the practice, and all of the population groups, as requires improvement for providing responsive services.

The practice was rated as requires improvement for responsive because:

  • Patients were not able to access care and treatment from the practice within an acceptable timescale for their needs.
  • Patients feedback highlighted concerns about the appointment booking system, availability of appointments with the GPs and the continuity of care.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs. For example, the practice was proactive in offering online services, which included online appointment booking; an electronic prescription service and online registration.
  • The practice website was well designed, clear and simple to use featuring regularly updated information.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services. For example, there were accessible facilities, which included a hearing loop, a disabled toilet and baby changing facility. However, the practice did not provide a low level desk at the front reception and the front door used to enter the practice did not have an automatic door activation system.
  • The practice had installed a touch screen self check-in facility to reduce the queue at the reception desk. However, the self check-in screen was faulty on the day of inspection.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • The practice sent text message reminders of appointments.

Older people:

This population group was rated as requires improvement for responsive care.

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.

People with long-term conditions:

This population group was rated as requires improvement for responsive care.

  • Patients with a long-term condition did not receive an annual review in a timely manner to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

This population group was rated as requires improvement for responsive care.

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

This population group was rated as requires improvement for responsive care.

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible and flexible. For example, the practice offered extended opening hours every Tuesday and Wednesday from 6.30pm to 8.30pm.
  • In addition, the patients at the practice were offered extended hours appointments through a locality hub Monday to Friday from 6.30pm to 8pm, Saturday and Sunday from 8am to 6pm at three locations. This extended hours service was funded by the local CCG.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.

People whose circumstances make them vulnerable:

This population group was rated as requires improvement for responsive care.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

This population group was rated as requires improvement for responsive care.

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held GP led dedicated monthly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.

Timely access to care and treatment

Patients were not able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Feedback from patients and staff reported that waiting times, delays and cancellations were not managed appropriately. Patients did not receive timely access to care and treatment.
  • Patients feedback highlighted concerns about the appointment booking system, availability of appointments with the GPs and the continuity of care. A member of the patient participation group (PPG) we spoke with highlighted similar concerns regarding lack of appointments and poor continuity of care.
  • We checked the online appointment records and noted that the next pre-bookable appointments with named GPs were available within three to four weeks. We noted that the next pre-bookable appointment with any GP was available within three to four weeks. The practice was offering 27 to 28 GP sessions per week.
  • Results from the July 2017 annual national GP patient survey showed that patients’ satisfaction with how they could access care and treatment was comparable to or below the local and national averages.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Pre-bookable appointments could be booked up to six weeks in advance.
  • Opening hours, extended hours and out of hours details were not advertised outside the main entrance. However, these details were advertised on the practice website.

Listening and learning from concerns and complaints

The practice 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 complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Requires improvement

Updated 22 August 2018

We rated the practice as requires improvement for providing a well-led service.

The practice was rated as requires improvement for well-led because:

  • There was a lack of local clinical leadership and good governance.
  • Staff reported lack of responsiveness and support from the head office, and they did not have confidence that their concerns would be addressed in a timely manner.

Leadership capacity and capability

Staff we spoke with informed us the provider had struggled to provide a local clinical leadership in the practice to deliver high-quality, sustainable care.

  • There were two partners and they had a contract with the NHS England to provide health and care services at the practice. The partnership had a relationship with Virgin Care Services Limited to provide back office functions. Both partners did not offer any clinical GP sessions at the practice. Staff we spoke with informed us that both partners were not visible at the practice and did not provide any local leadership at the practice. One of the partners was in a clinical director role had taken part in the clinical meetings. The provider had appointed a GP as a clinical lead and a service manager to run the practice.
  • The management team we spoke with was knowledgeable about issues and priorities relating to the quality and future of services. The partners understood the challenges and were addressing them.
  • They were planning to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a strategy but it did not work effectively to deliver high quality, sustainable care.

  • There was a clear vision and mission statement. This included providing a high quality, accessible care in a safe, responsive and courteous manner. The practice did not have a formal documented business plan.
  • We found details of the aims and objectives were part of the practice’s statement of purpose. The practice aims and objectives included providing the highest possible quality of care. This also included working together as a team to promote the best practice and provide a high standard of medical care.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice did not monitor progress against delivery of the strategy on regular basis. However, they had carried out reviews and audits two to four weeks before this inspection, which had identified the concerns and they developed comprehensive action plans to address these concerns.

Culture

The practice aspired to a culture of high quality sustainable care however not all staff felt supported to do this.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. However, they did not have confidence that these would be addressed in a timely manner. Staff reported lack of responsiveness and poor support from the head office.
  • 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. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was some emphasis on the safety and well-being of all staff, but improvements were required. For example, staff we spoke with raised dissatisfaction regarding both clinical and non-clinical staffing levels at the practice. Staff we spoke with and water temperature monitoring records we had seen reflected there was no hot water in the kitchen, staff and patients’ toilets since January 2018. This issue had been resolved after we had announced the inspection.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

The practice had a governance framework but this did not always support the delivery of safe and effective care.

  • There was a lack of good clinical governance to ensure effective monitoring and assessment of the quality of the service.
  • There was limited evidence of quality improvement activity.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice specific policies were implemented and were available to all staff.
  • There were arrangements in place for planning and monitoring the number of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics. The clinical and non-clinical staff we spoke with and written feedback we received on the day of the inspection raised concerns regarding inappropriate staffing levels of both clinical and non-clinical staff.

Managing risks, issues and performance

There were processes in place for managing risks, however, improvements were required.

  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. However, monitoring of specific areas such as calibration of medical equipment, staffing levels, childhood immunisations and the management of blank prescription forms were not always managed appropriately.
  • The practice had recently implemented processes to manage current and future performance. Practice leaders had oversight of safety alerts and complaints.
  • Prescribing audits had a positive impact on quality of care and outcomes for patients.
  • There was an arrangement for supporting and managing staff when their performance was poor or variable. However, the local management staff we spoke with informed us they did not receive appropriate and timely support from the head office to manage poor staff performance effectively.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice recently acted on appropriate and accurate information.

  • The practice had carried out a recent quality review to identify the reasons for significant reduction in QOF data for 2017-18 and this operational information was used to improve performance. Performance information was combined with the views of patients. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • 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.

Engagement with patients, the public, staff and external partners

The practice encouraged and valued feedback from patients, the public, staff and external partners.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

Please refer to the evidence tables for further information.

Checks on specific services

Older people

Requires improvement

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement