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Inspection carried out on 7 February 2019

During a routine inspection

We carried out this announced comprehensive inspection at Alexandra Surgery on 7 February 2019. We had previously carried out an announced comprehensive inspection on 18 January 2018. At that time the service was rated as requires improvement. It was rated as requires improvement for the safe, effective and well led domains and good for caring and responsive.

The areas where we said that the provider must make improvement were:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care with regards to: clinical governance, risk management, quality improvement, monitoring care and treatment for patients and patient engagement.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where we said the provider should make improvements were:

  • Ensure there is an effective system for monitoring prescriptions that have been issued but not collected.
  • Review the criminal records checks procedure for the practice.
  • Ensure business continuity and skill mix if the practice manager is absent for a significant period of time.
  • Improve uptake for screening programmes.

At this inspection we found that the practice had addressed all of the issued from the previous inspection, and have rated this practice as good overall and good for all population groups.

We found that:

  • 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 the scheduling of clinical meetings so that further clinical staff may attend.
  • Review safeguarding and serious incidents even where concerns have not been raised.
  • Continue to review patient outcomes where scores are lower than the national or Clinical Commissioning Group area average, particularly in relation to uptake of cervical cancer screening.

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 18 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall.

(Previous inspection 1 December 2015 the practice was rated as Good.)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

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

We carried out an announced comprehensive/focused inspection at Alexandra Surgery on 18 January 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out in line with our next phase inspection programme.

At this inspection we found:

  • The practice had some well-managed systems in place to keep people safe and reduce risk so that safety incidents were less like to happen. When incidents did happen, the practice learned from them and improved their processes.

  • Not all safety systems were operating effectively; including health and safety and emergency risk management.

  • Some staff had not received mandatory training in safeguarding children, the Mental Capacity Act and information governance.

  • Patients’ needs were effectively assessed and care and treatment was in line with evidence- based guidance.

  • Performance data, particularly for people with long-term conditions was lower than local and national averages.

  • Due to some inaccuracies in the performance data, the medical record system used was not able to assist the practice in monitoring patients effectively enough.

  • Although there was evidence of some measures to review the effectiveness of the care, there was limited evidence that the practice was auditing medicines and antimicrobial use.

  • There were many examples where staff involved and treated patients with compassion, kindness, dignity and respect.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice offered a flexible range of appointments and services.

  • There was a strong culture of support, openness and transparency among staff and leaders.

  • Governance processes and systems for business planning, risk management, performance and quality improvement were not always operating effectively.

  • Systems for engaging with patients and acting on concerns were not well-established.

We saw areas of outstanding practice:

The practice provided timely care in response to specific patient needs.

  • Practice nurses visited housebound patients who lived out of area if they required blood tests, but were unable to access phlebotomy services in their area.

  • GPs took urgent blood samples from patients during consultations to reduce delays in patients getting care and treatment.

  • GPs worked closely with mental health teams. There was evidence of joint assessments with a consultant psychiatrist to get urgent mental health support for patients.

  • GPs provided structured, regular appointments with some patients with complex, severe mental health needs on a fortnightly basis.

There was evidence of the practice showing kindness, respect and compassion to vulnerable patients and families.

  • We saw examples of the practice providing individualised care provided to support vulnerable patients who were anxious about attending hospital appointments.
  • One of the GPs provided out of hours support to patients’ families for those patients with severe mental health needs.

  • We received 41 comments cards; all but one were highly positive about the level of care experienced.

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

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care with regards to: clinical governance, risk management, quality improvement, monitoring care and treatment for patients and patient engagement.

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Ensure there is an effective system for monitoring prescriptions that have been issued but not collected.

  • Review the criminal records checks procedure for the practice.

  • Ensure business continuity and skill mix if the practice manager is absent for a significant period of time.

  • Improve uptake for screening programmes.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 1 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Alexandra Surgery on 1 December 2015. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Most risks to patients were assessed and well managed, with the exception of robust medicines management processes.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Data showed patient outcomes were mixed; either below, in line with or above average for the locality.
  • Audits had been carried out with evidence that they were driving performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice worked with the local Clinical Commissioning Group (CCG) to ensure practice services met patients’ needs.
  • Patients said they found it easy to make an appointment and that 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.
  • Information about services and how to complain was

    available for patients, but it did not contain enough detail about the complaints process. There was also limited information available relating to translation services, health conditions and support services available.

  • Policies and procedures were accessible for staff and were updated annually to reflect changes in practice systems.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice proactively sought feedback from staff and patients, which it acted on and they had a Patient Participation Group (PPG) although this had been less active over the last two years.

The areas where the provider should make improvement are:

  • Ensure that current medicines management procedures are robust, to include effective monitoring of the vaccine refrigerator temperatures and recording of emergency medicines checks.
  • Ensure that the practice has a record of all assessed risks relating to health and safety of the premises including those for asbestos.
  • Ensure visual and written information is available for patients in the waiting area, specifically relating to complaints, translation services, bereavement and carers support.
  • Ensure that clinical meeting minutes contain comprehensive information and action points to be able to monitor patients effectively.
  • Ensure that detailed minutes of partnership and governance meetings are kept.
  • Work to improve patient satisfaction with reception services and further review how the practice can reduce the number of delayed appointments.
  • Improve the use and effectiveness of the Patient Participation Group in gathering and implementing patient feedback.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice