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Reepham & Aylsham Medical Practice Good

Reports


Review carried out on 15 November 2019

During an annual regulatory review

We reviewed the information available to us about Reepham & Aylsham Medical Practice on 15 November 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 16 January 2018

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Reepham and Aylsham Medical Practice on 19 September 2016. The practice was rated as good for providing effective and caring services, requires improvement for providing responsive and well led services and inadequate for providing safe services. Overall the practice was rated as requires improvement.

We undertook a comprehensive inspection of Reepham and Aylsham Medical Practice on 06 July 2017 under Section 60 of the Health and Social Care Act 2008 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 19 September 2016. The practice was rated as good overall and requires improvement for providing safe services. The full comprehensive report following the inspection on 19 September 2016 and 06 July 2017 can be found by selecting the ‘all reports’ link for Reepham and Aylsham Medical Practice on our website at www.cqc.org.uk.

We undertook a follow up focused inspection of Reepham and Aylsham Medical Practice on 16 January 2018. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.

Overall the practice is still rated as good, and has been rated as good for providing safe services.

Our key findings were as follows:

  • All equipment in the emergency bag was in date. There was a comprehensive policy and log in place to support the new checking system.

  • There was a system in place to monitor the use of blank prescription stationary which was in line with relevant guidance.

  • There was a system in place to record, learn from and discuss incidents such as near misses in the dispensary.

  • There were two dispensaries and the system for managing uncollected scripts was uniform across both dispensaries and ensured GPs were informed when medicines were not collected.

  • At the inspection on 06 July 2017, we found that exception reporting for 2015/16 for ‘the percentage of patients with cancer, diagnosed within the preceding 15 months, who had a patient review recorded as occurring within six months of the date of diagnosis’ was significantly higher than the local and national averages. (Exception reporting is the removal of patients from the Quality and Outcomes Framework calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). The practice had run an audit and data from 2016/17 showed this exception reporting had reduced and was comparable to the local and national averages.

  • The practice had implemented an audit calendar which ensured second audit cycles were completed in a timely manner. The practice had also implemented a system whereby each member of staff completed a yearly audit for professional development. Some of these audits included prescribing for urinary tract infections, prescribing blood thinning medicines, appointments and an audit of the practice website. The practice also completed audits on population groups to ensure audits were relevant to their practice. For example, the practice had completed an audit to ensure they had appropriately identified all patients approaching the end of life. Systems and processes were implemented and this resulted in increased staff awareness of the patient’s condition.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 6 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Reepham and Aylsham Medical Practice on 19 September 2016. The practice was rated as good for providing effective and caring services, requires improvement for providing responsive and well led services and inadequate for providing safe services. Overall the practice was rated as requires improvement. The full comprehensive reports on the 19 September 2016 inspection can be found by selecting the ‘all reports’ link for the Reepham and Aylsham Medical Practice on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at the Reepham and Aylsham Medical Practice on 6 July 2017. 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.
  • Risks to patients were assessed and generally well managed but there were improvements required in relation to management of emergency medicines and the recording of near miss incidents in the dispensaries. Blank prescriptions were kept secure at all times and locked away when the dispensary was closed. Prescription pads were signed out to a responsible prescriber but not tracked through the practice. This was addressed immediately when we raised this with the practice.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge, and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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. Staff told us they were able to undertake development opportunities.
  • The provider was aware of, and complied with, the requirements of the duty of candour.

The area where the provider must make improvement are:

  • Ensure systems and processes provide safe management of medicines.

The areas where the provider should make improvement are:

  • The current audit programme should be reviewed to take into account current evidence based guidance.
  • Effectively track prescription pads through the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 19 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Reepham and Aylsham Medical Practice on 19 September 2016. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not always thorough enough to ensure that identified learning led to improvement.
  • Patients were at risk of harm because systems and processes had not been properly implemented in a way to keep them safe. For example the management of patient safety alerts, health and safety risks, recruitment procedures and disclosure and barring service checks (DBS), chaperone and safeguarding procedures, medicines management and medical emergencies.

  • The practice was visibly clean and tidy and infection control procedures had been recently reviewed. However systems for monitoring infection control practice were not well embedded.

  • Data showed that patient outcomes were similar to or higher than the national average.

  • Although several audits had been carried out, few second cycle audits had been completed to demonstrate improvement to patient outcomes.

  • The majority of patients said they were treated with compassion, dignity and respect.

  • Practice staff reviewed the needs of its local population and worked hard to engage with local NHS teams, commissioners and other health and care professionals to meet the needs of their patients.

  • Patients said they were always able to get an urgent appointment although it was not easy to make an appointment with their preferred GP.

  • Information about how to complain was available and easy to understand and evidence showed the practice mostly responded to issues in a timely manner although one complaint had not been addressed for three months. The learning from complaints was not always shared with staff and other stakeholders to support improvements.

  • The practice had a number of policies and procedures to govern activity, but some of these required a review.

The areas where the provider must make improvements are:

  • Identify and investigate safety incidents and complaints thoroughly so that the learning is actioned, shared with staff and reviewed. Review the staff’s knowledge and understanding of the duty of candour and their responsibilities to patients.

  • Implement an effective system for dealing with patient safety alerts, including MHRA alerts and updates.

  • Ensure that the systems in place are effective in safeguarding vulnerable adults and children.

  • Ensure there is adequate leadership and staffing in the dispensary. Systems and processes in the dispensary must be reviewed to ensure that staff manage medicines in a safe way.

  • Ensure recruitment arrangements are clear and that disclosure and barring service checks for staff are completed appropriately before staff commence employment.

  • Ensure that staff who act as chaperones are adequately trained for the role and patients are made aware of their right to request this support.

  • Ensure that health and safety risk assessments and audits are established and any associated actions are completed so that adequate control measures are implemented in a timely way.

  • Ensure that procedures for managing medical emergencies are in place, shared with staff and that equipment is accessible and ready for use.

  • Ensure that health and safety audits are established and actioned in a timely manner.

In addition the provider should:

  • Embed a system for monitoring infection control procedures on a regular basis, including evidence that appropriate cleaning has taken place.

  • Review and update the business continuity plan.

  • Review the complaints process so that any learning outcomes are put into action and shared appropriately.
  • Carry out two cycle audits to improve patient outcomes including improvement already identified in recording patient consent.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 12 February 2014

During a routine inspection

Most people we spoke with told us they were happy with the service they received saying how excellent the service was and how caring the staff were.

Some people who had pre-booked appointments said they sometimes find they can wait a long time to see the doctor. However they all said that they felt listened to and that they were treated with respect and dignity. They told us appointments were usually thorough, that the doctor took time to explain things, that they were of sufficient length and not rushed.

One person told us, �When we moved to the village we checked the practice out by asking our neighbours about them. We haven�t been disappointed.� Another person told us, �The doctor came to the house to see my dad as an emergency. By the afternoon he [dad] was having investigations at the local hospital. That�s what I call excellent service.�

However the provider may wish to note that some of the people we spoke with said it was difficult at times to get through to the practice on the phone to make an appointment. One person told us, �It can be difficult to get an appointment on the phone but it is getting better�.

The practice building was easy to access with ample parking. There were pleasant gardens around the building and all windows facing public areas had blinds and privacy glass. There was a toilet accessible to people with disabilities on the ground floor and a baby changing room.