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Inspection carried out on 24/01/2020

During a routine inspection

We carried out an announced comprehensive inspection at Locking Hill Surgery on 24 January 2020 as part of our inspection programme.

At the last inspection on 29 January 2019 we rated the practice as requires improvement for providing safe and effective services because:

  • The practice system was not effective in ensuring that patients who required monitoring and reviews were recalled appropriately.
  • The monitoring of patients prescribed high risk medicines was not effective.
  • The system for managing safety alerts was not effective.
  • There was no protocol for reception staff of when to advise patients to call 999 in the case of a medical emergency.
  • Exception reporting was higher than local and national averages and performance was lower for Mental Health indicators.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 except for families, children and young people.

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:

  • Continue to monitor and address exception reporting data that was outside of the expected range.
  • Continue to implement actions to improve the uptake for childhood immunisation.
  • Monitor and implement actions to increase the number of patients, with certain conditions whose notes record their smoking status.

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 29 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Locking Hill Surgery on 29 January 2019 as part of our inspection programme.

The practice was previously inspected in January 2015 and was rated as good overall and requires improvement for providing safe services.

We undertook a comprehensive inspection of the practice in May 2017 where the practice was rated as inadequate for providing safe, effective and well led services as well as overall, requires improvement for providing responsive service and good for providing caring services.

A follow up inspection was undertaken in November 2017 to check the practice had addressed the breaches of regulations we identified at the May 2017 inspection.

A comprehensive inspection was undertaken in January 2018 to confirm the practice had met the legal requirements following the previous inspection. At the time the practice was rated as Good overall.

The full reports of these previous inspections can be found by selecting the ‘all reports’ link for Locking Hill Surgery on our website at

We based our judgement of the quality of care at this service on a combination of:

We have rated this practice as good for providing caring, responsive and well-led services.

The practice is rated as good for all population groups except for patients with long term conditions and patients experiencing poor mental health (including people with dementia) where we rated the practice as requires improvement for providing effective care. The ratings in those population groups has led to the Effective key question to be also rated as requires improvement. The practice is also rated as requires improvement for providing safe services as well as overall. This was because:

However, we found that:

The areas where the provider must make improvements are:

The areas where the provider should make improvements are:

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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

Inspection carried out on 23 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This

report covers the full comprehensive inspection we carried out at Locking Hill

Surgery on 23 January 2018.

Previously,

we carried out an announced comprehensive inspection on 14 January 2015, when

the overall rating for the practice was good. However, we found they required

improvement for the delivery of safe services. We carried out another announced

comprehensive inspection at Locking Hill Surgery on 9 May 2017 to follow up on

the previous inspection and found further breaches in the regulations. Overall

we rated the practice as Inadequate and issued three warning notices. We then carried

out an announced focused inspection on 15 November 2017 to confirm that the

practice had met the legal requirements with regard to these warning notices. The

full reports of these previous inspections can be found by selecting the ‘all

reports’ link for Locking Hill Surgery on our website at www.cqc.org.uk.

This practice is now

rated as Good overall.

The key questions are rated as:

  • Are services safe?

    – Good

  • Are services

    effective? – Good

  • Are services

    caring? – Good

  • Are services

    responsive? – Good

  • Are services

    well-led? - Good

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 – Good

  • People with

    long-term conditions – Good

  • Families, children

    and young people – Good

  • Working age people

    (including those retired and students – Good

  • People whose

    circumstances may make them vulnerable – Good

  • People

    experiencing poor mental health (including people with dementia) - Good

Our key findings were:

  • Since our inspection in May 2017, the practice had recognised a need to

    change and had reviewed and revised many systems and processes across all areas

    of the practice. In the process of doing these reviews they had sought help and

    advice from a range of external bodies and independent consultants. They had

    also engaged with their patient participation group and staff team.

  • The practice had introduced a range of new and revised policies and

    procedures, such as a health and safety policy and medicine management

    policies.

  • The practice had made improvements to the building, such as fitting a

    new fire detection and alarm system.

  • The practice had clear systems to manage risk so that safety incidents

    were less likely to happen. When incidents did happen, the practice learned

    from them and improved their processes.

  • The practice routinely reviewed the effectiveness and appropriateness of

    the care it provided. Care and treatment was delivered according to evidence-

    based guidelines.

  • The most recent published Quality Outcome Framework results were 99% of

    the total number of points available compared with the clinical commissioning

    group average of 98% and national average of 95%. The data showed the practice

    was performing broadly in line with national averages.

  • Results from the July 2017 annual national GP

    patient survey showed patients rated the practice higher than average in many

    areas of care. For example, 96% of patients who responded said the last GP they

    spoke to was good at treating them with care and concern, compared to the local

    average of 90% and national average of 86%, and 90% of patients who responded

    said that the last time they wanted to speak to a GP or nurse they were able to

    get an appointment, compared to the local average of 85% and national average

    of 76%.

  • The practice recognised that further ongoing

    work was required to ensure all the improvements made in the last six months

    continued to be embedded into the practice.

 

The areas where the provider should make improvements are:

  • Continue to develop their policy on essential training.

  • Continue to work to embed and keep under review recent improvements,

    particularly those relating to management and governance arrangements.

  • Continue to improve the identification of carers.

This service was

placed in special measures on 20 July 2017. Since then the practice has made

significant improvements across many areas of the practice and is now meeting

the regulations. I am therefore taking the practice out of special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 15 November 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This report covers the focused inspection we carried out at Locking Hill Surgery on 15 November 2017.

Previously, we carried out an announced comprehensive inspection on 14 January 2015, when the overall rating for the practice was good. However, we found they required improvement for the delivery of safe services. We carried out another announced comprehensive inspection at Locking Hill Surgery on 9 May 2017 to follow up on the previous inspection and found further breaches in the regulations. Overall we rated the practice as Inadequate and issued three warning notices.  The

warning notices we served related to Regulation 12 –Safe Care and Treatment, Regulation 17 - Good Governance, and Regulation 18 – Staffing, of the

Health and Social Care Act 2008. The practice was required to correct the regulatory breaches set out in the warning notice relating to Regulations 12 and 18 by 1 September 2017 and Regulation 17 by 27 October 2017.

The full comprehensive report of the 9 May 2017 inspection can be found by selecting the ‘all reports’ link for Locking Hill Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 November 2017 to confirm that the practice had met the legal requirements with regard to the warning notices served following the comprehensive inspection in May 2017. This report covers our findings in relation to those requirements. Due to the focused nature of this inspection the ratings for the practice have not been updated. We will conduct a comprehensive inspection at a later date to determine their compliance with all requirements of the Health and Social Care Act 2008.

We found the practice had reviewed and revised many systems and processes.  They had worked with a range of groups including, Gloucestershire Clinical Commissioning Group, NHS England and their patient participation group to achieve this. We found they had made significant improvements and were now meeting most of the regulations they had previously breached that had led to the issuing of the warning notices. We found that some systems had been introduced too recently to enable us to make an adequate assessment of their continued effectiveness in meeting the regulations previously breached.

Our key findings were:

  • The practice had revised its governance arrangements and management meetings now included team managers.  They had reviewed and clarified the roles and accountability of the partners and team managers. 

  • There was a new two year strategy in place.

  • We saw evidence the practice had reviewed and revised many of their policies and procedures and introduced some new ones, such as a whistleblowing policy.

  • We were informed the practice had worked with all the teams within the practice and had achieved a more inclusive and supportive culture.  We spoke to a number of staff who confirmed this.

  • The practice had appropriate systems to assess, monitor, manage and mitigate risks to the health and safety of patients who used their services. This included fire safety and legionella.  In some cases the practice system for recording actions taken to deal with issues identified was unclear.

  • We were told all staff had received an appraisal in the last year and we saw documentary evidence to support this.  The practice had also introduced a system of staff having monthly or bi-monthly one-to-one sessions with their line manager.

  • We saw evidence staff had received essential training appropriate to their role. 

  • The practice was in the process of introducing a new IT management system to help manage and record a range of issues including staff training and appraisals.  We were told this system had not been fully introduced and that the process of transferring records was ongoing. 

  • The practice had reviewed and revised their system for dealing with complaints.  Although patients were given information on how to escalate complaints if they were not satisfied with the practice response, this information was not always included in the final letter from the practice, as recommended in guidance.

The areas where the provider should make improvements are:

  • Review management systems to record actions taken and completed in relation to areas identified as requiring action, such as those from a risk assessment or infection control audit.

  • Review the complaints process so that patients are given information on how to escalate a complaint if they are not satisfied with the practice response.

  • Continue to work to ensure recent improvements and changes made become embedded in the practice.

The Care Quality Commission is satisfied that the areas within the warning notices have been addressed adequately and the practice is now compliant with regard to the notices. The practice remains in special measures until a full comprehensive inspection is carried out by the Care Quality Commission. Therefore the overall rating remains inadequate. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 9 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We

carried out an announced comprehensive inspection at Locking Hill Surgery on 14

January 2015. The overall rating for the practice was good. However, we found

they required improvement for the delivery of safe services. The full

comprehensive report for the January 2015 inspection can be found by selecting the

‘all reports’ link for Locking Hill Surgery on our website at www.cqc.org.uk.

This

announced comprehensive follow up inspection

was

undertaken

on 9 May 2017. Overall the

practice is now rated as inadequate.

Our key findings across all the areas we inspected

were as follows:

  • When we inspected the practice in January 2015 we found some breaches of

    the regulations and told the practice they must take action to correct these. On

    this inspection we found no evidence that some of the breaches had been actioned.

    For example, on this inspection we did not find evidence that any assessments

    of risks to patients and staff had been carried out where action had been taken

    to minimise risks identified. This was identified as a regulatory breach in

    January 2015.

  • Not all staff knew how to report concerns,

    incidents and near misses. There was no significant events policy and the

    reporting form was not easily available to all staff.

  • There was no governance or management processes to ensure all staff had

    annual appraisals or received the training essential to their role.

  • Not all the recommended emergency medicines were available in the

    practice and we found some medicines such as salbutamol stored in an unsecured

    location.

  • There was limited evidence that quality improvements including audit was

    driving improvement in patient outcomes.

  • The arrangements for storing vaccines were not in line with current guidance.

  • Complaints were not always dealt with appropriately.

  • Patients said they were treated with

    compassion, dignity and respect.

  • Data from the national GP patient survey showed patients rated the

    practice higher than others for several aspects of care. For example, 89% of

    patients described their experience of making an appointment as good compared

    with the CCG average of 80% and the national average of 73%.

     

The areas where the provider must make

improvements are:

  • Ensure they have effective systems for

    reporting, investigating and learning from significant events and informing

    patients where appropriate.

  • Ensure they have effective systems to improve

    the service where service improvements are identified as being required.

  • Ensure their safeguarding policy is in line

    with recognised guidance and that all staff receive training to the level

    appropriate to their role.

  • Ensure all appropriate recruitment checks are

    carried out.

  • Ensure they assess the risks relating to the

    health, safety and welfare of patients, staff and visitors to the practice and

    have plans that ensure adequate measures are taken to minimise those risks.

  • Ensure all staff received such appropriate

    training, professional development, supervision and appraisal as is necessary

    to enable them to carry out the duties they are employed to perform.

  • Ensure the arrangements for storing vaccines

    are in line with current recognised guidance.

  • Ensure they have an adequate range of emergency medicines that are kept

    secure and that all medicines and medical equipmentare in date and able to be

    used.

  • Ensure they have effective systems to ensure all staff complete the

    essential training appropriate to their role.

  • Ensure that all staff receive an annual appraisal or performance review.

  • Ensure they have induction information

    available for locums.

  • Ensure they have an effective system for

    recording, investigating and responding to complaints.

  • Ensure they have an adequate range of

    policies and procedures and that these are easily assessable to all appropriate

    staff.

  • Develop guidance and systems to ensure

    letters faxed to the practice out of hours are effectively actioned.

In addition the provider should:

  • Ensure external clinical waste bin is secure

    in its location.

  • Develop a plan in relation to quality

    improvement activity and ensure that that lessons learnt and any changes made

    are adequately documented and shared with all appropriate staff.

  • Ensure verbal consent received when fitting

    intrauterine devices is recorded in the patient’s notes.

  • Ensure they have made reasonable adjustments

    for patients with disabilities.

  • Ensure they routinely check the oxygen

    cylinders.

I am placing this service in special

measures. Services placed in special measures will be inspected again within

six months. If insufficient improvements have been made such that there remains

a rating of inadequate 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.

The service will be kept under review and if

needed could be escalated to urgent enforcement action. Where necessary,

another inspection will be conducted within a further six months, and if there

is not enough improvement we will move to close the service by adopting our

proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the

service 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 14 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Locking Hill Surgery on 14 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to require improvement for providing safe services. It was good for providing effective, caring, responsive and well-led services for older people, people with long term conditions, families children and young people, people of working age including those recently retired an students, people whose circumstances make them vulnerable and people with poor mental health including people with dementia.

Our key findings were as follows:

  • Data showed patient outcomes were at or above the average for the locality.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice had a clear vision and strategy and staff were clear about the vision and their responsibilities in relation to this.
  • The practice proactively sought feedback from patients which it acted on.
  • The practice engaged with an external consultant to review the appointments system and changed what they were doing. The day was divided into three shorter surgeries so that appointments were more likely to be on time and patients had access to appointments at lunchtime.

  • A ‘late start GP’ often covered urgent morning visits rather than patients having to wait until lunchtime.

  • Triage nurses who saw patients the same day for minor illness. As the practice offered same day access appointments any patient who felt they needed to be seen the same day could have an appointment.

  • The practice had started a comprehensive audit on atrial fibrillation (irregular heart rhythm) and whilst this has not been completed had raised awareness in the practice of routine pulse checks in older patients and those with cardio-vascular risk factors.

  • Same day appointments were available for patients with poor mental health.

  • If patients with poor mental health did not attend for an annual review and were not seen opportunistically when their mental health could be reviewed a GP would arrange to visit them.

We saw an area of outstanding practice:

  • GPs discussed with patients the options available to them for their health and wellbeing. This included options for prescriptions for counselling services , access to an exercise facility or self-help books and art therapy.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure the practice has a health and safety policy, to include contingency planning in the event of an emergency . This must include assessment of risk to patients, staff and visitors to the practice and measures to minimise those risks.

In addition the provider should:

  • Record as evidence, the induction and all training completed by staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice