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Review carried out on 28 January 2020

During an annual regulatory review

We reviewed the information available to us about Peartree Practice on 28 January 2020. 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 27 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Chessel Practice on 27 March 2019 as part of our inspection programme.

This service was placed in special measures in September 2017. We found that the practice had improved when we undertook the follow up inspection on 20 February 2018.

However, the practice needed time to ensure that there was more evidence that the improvements were embedded properly and that the improvements were sustained.

At this inspection were saw that improvements had been maintained.

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 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learnt from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment were delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.

Whilst we found no breaches of regulations, the provider should:

  • Review processes for the management and checks of locum GPs.
  • Continue to maintain Quality Outcome framework performance.
  • Continue to Improve patient feedback.

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 February 2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous inspection 06/2017 – Inadequate).

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

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

As a result of the inspection in June 2017 a warning notice was served and the practice had been placed into special measures in September 2017. The practice was re inspected in October 2017 to follow up on the warning notice and was found to have completed the requirements of the notice.

We carried out an announced comprehensive inspection at Chessel Practice on 20 February 2018 to check that sufficient improvements had been made to bring the practice out of special measures and improve the rating from Inadequate.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learnt from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment were delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system was not easy to use and reported that they were not always able to access care when they needed it.
  • All staff received up-to-date safeguarding and safety training appropriate to their role.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a focus on continuous learning and improvement at all levels of the organisation.
  • There was a system for receiving and acting on safety alerts. The practice learned from external safety events as well as patient and medicine safety alerts.

The areas where the provider should make improvements are:

  • Continue to review the care and treatment offered for all patients with long term conditions such as demonstrated through the Quality and Outcomes Framework results.

  • Review the patient experience and take account of feedback such as the national GP patient survey results.

This service was placed in special measures in September 2017. We found that the practice had improved when we undertook the follow up inspection on 20 February 2018

However, the practice needs time to ensure that there is more evidence that the improvements are embedded properly and that the improvements are sustained.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 19 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at Chessel Practice on 19 October 2017 to follow up on two warning notices.

Our previous inspection in June 2017 was a comprehensive inspection and we rated the practice inadequate overall and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report. As a result of the inspection warning notices were served. The timescale given to comply with the warning notice was 11 September 2017.

The warning notices served related to regulations 12 and 17 Health and Social Care Act as a result of the following issues:

Risk assessments relating to the health, safety and welfare of people using services were not fully completed and reviewed regularly by people with the qualifications, skills, competence and experience to do so.

Safety records, incident reports, national patient safety alerts and minutes of meetings showed that lessons were not always completely shared to make sure action was taken to improve safety in the practice.

Meeting minutes were not recorded with details of local reviews of significant events or required action and who was dealing with the action.

Medication reviews did not always align with, people’s care and treatment assessments, plans or pathways and should be completed and reviewed regularly when their medication changes.

The practice did not ensure all leaders had the necessary experience, knowledge, capacity and capability to lead effectively. We were told that there was no clinical lead present at the practice on a day to day basis

Governance arrangements and risk management were not fully embedded. The partners were not always visible in the practice and staff told us they were not always approachable and took the time to listen to members of staff. Staff told us that there was poor communication in the practice between the staff and GP partners.

The registered GP partners had minimal knowledge of what was happening during day-to-day services at the practice and did not have the capacity or capability to lead effectively.

At our inspection on 19 October 2017 we found the provider had complied with the warning notice in relation to regulations 12 and 17.

Our Key findings were:

There were now more systems and processes in place which need to be imbedded to demonstrate consistency in delivery; for example

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risk assessments for areas such as Legionella had been carried out, and there was a system to monitor and act on the findings of the assessments.
  • Practice policies and procedures were now appropriately reviewed and updated to ensure their content was current and relevant.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • A programme of audits had been established.
  • A new GP partner was now the clinical lead at the practice.
  • Since being placed in Special Measures, the practice had met with the clinical commissioning group monthly and had worked to both reassure them and benefit from their input, by collaborating on a progress action plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 20 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection carried out on Tuesday 20 June 2017 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 27 October 2016. This report covers our findings in relation to those requirements.

This practice has a branch practice at 4 Chessel Avenue, Bitterne, Hampshire, SO19 4AA. During this inspection we did not visit the branch practice.

The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Chessel Practice on our website at www.cqc.org.uk.

Overall the practice was rated as requires improvement following the October 2016 inspection. The practice was rated as follows Safe: Good, Effective: Requires Improvement, Caring: Good, Responsive: Requires Improvement, Well Led: Requires Improvement.

Our key findings at the 20 June inspection were:

  • The practice was able to provide written evidence that all staff had now received an appraisal. The practice now had a process in place to identify when the next staff appraisals were due.
  • The practice had reviewed and was working to improve the number and frequency of patient appointments. The telephone system was being monitored to increase the number of appointment calls and new reception staff were being employed and longer appointments, urgent appointments and home visits were available for patients when needed.

There was no one who had oversight of clinical performance and activity to maintain, and where needed, improve care and treatment. Although we were told at the time of this inspection that a GP from the other practice was always available to assist with clinical leadership.

  • Learning from significant events was not always shared with all staff as relevant and recorded. Meeting minutes were not recorded with details of local reviews of significant events.
  • Medication audits were not always followed up and actions completed to ensure patients were kept safe.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • 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 way significant events are recorded and shared with all staff.
  • Review how the practice can improve the quality and effectiveness of clinical care to patients such as the measures found within the quality outcome framework (QOF).
  • Complete all recommendations made in the legionella risk assessment.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give patients who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 27 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection carried out on Thursday 27 October 2016 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 Thursday 25 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Chessel Practice on our website at www.cqc.org.uk.

Overall the practice is now rated as requires improvement.

At our previous inspection, we found that the practice had not ensured that:

  • Lessons were learnt and action taken following significant event investigations to improve the safety in the practice.
  • Clinical audits and re-audits were carried out to improve patient outcomes.
  • Appraisals were undertaken for all staff.
  • A Legionella risk assessment had been completed..

Our key findings for this inspection were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Reviews and investigations had been introduced and were taking place.
  • Data showed patient outcomes were low compared to the locality and nationally.
  • New audits had been carried out and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • A Legionella risk assessment had been completed.
  • Patient survey results showed lower satisfaction with this practice than nationally however the majority of patients we spoke with said they were treated with compassion, dignity and respect.
  • The practice had commenced regular communication with all staff in a format that meant staff were aware of relevant changes in the practice.
  • The practice had started to review and update practice policy documents and implement them.
  • Training the practice felt was necessary, had been reviewed; such as for the Mental Capacity Act 2005, which had taken place.
  • The practice ensured all patients had a named GP.

The areas where the provider must make improvements are:

  • The provider must ensure that all staff had received regular appraisal.

In addition the provider should:

  • Make sure that learning from significant events is shared with all staff as relevant and recorded.
  • Review and improve the number and frequency of patient appointments.
  • Ensure the governance arrangements and risk management are fully embedded and increase the availability of the leadership in the practice for staff

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 25 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chessel Practice on 25 February 2016. Overall the practice is rated as requires improvement.

At the time of our visit the practice was preparing for a time of change and was being supported by Integrated Medical Holdings (IMH) who were providing back office functions and clinical support. IMH provided us with a comprehensive plan of how they were intending to work at the practice and the new practice manager had been recruited by IMH to introduce improvements at the practice.

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 thorough enough.
  • Data showed patient outcomes were low compared to the locality and nationally. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.

The areas where the provider must make improvements are:

  • Lessons must be learnt and action taken following significant event investigations to improve the safety in the practice.

  • Carry out clinical audits and re-audits to improve patient outcomes.

  • Carry out supervision and appraisals of all staff.
  • Carry out a Legionella risk assessment.

In addition the provider should:

  • Re-establish regular communication with all staff in a format that ensures staff are aware of the relevant changes in the practice.
  • Review and update practice policy documents.
  • Ensure that the relevant staff receive Mental Capacity Act 2005 training.
  • Ensure all patients had a named GP, those requiring it had a personalised care plan or structured annual review to check that their health and care needs were being met.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice