The Care Quality Commission
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  • GP practice

Archived: Reynard Surgery

Overall: Requires improvement read more about inspection ratings

10-10A Market Place, Mildenhall, Bury St Edmunds, Suffolk, IP28 7EF (01638) 552211

Provided and run by:
Reynard Surgery

Important: The provider of this service changed. See new profile

All Inspections

18/09/2019

During an inspection looking at part of the service

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Safe, effective and well led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and responsive.

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 requires improvement overall and for providing safe, effective and well-led services. The rating of good for providing caring and responsive services have been carried over from our previous inspection. The population group for people with long-term conditions and People experiencing poor mental health (including people with dementia) is rated as requires improvement; all other population groups were rated as good.

At this inspection we found:

  • Staff had the information they needed to deliver safe care and treatment.
  • The practice acted on all safety alerts received and there was a process to ensure actions were carried out.
  • Patients received effective care and treatment that met their needs.
  • The practice had systems for the appropriate and safe use of medicines, including medicines optimisation

We have rated the practice as requires improvement for providing a safe service because:

  • There was no clinical oversight of the practices risk assessments and policy updates and reviews. The safeguarding policy was incomplete; however, there were accurate information posters in every clinical room and staff spoken with were clear about their role.
  • Not all recruitment checks had been carried out in accordance with regulations. We found several gaps in the staff recruitment files which included a lack of references and gaps in training.

We have rated the practice as requires improvement for providing effective services and for all population groups with the exception of people with long term conditions and people experiencing poor mental health (including people with dementia) which we rated requires improvement. This was because:

  • The overall QOF achievement for COPD was lower than the CCG and national average and the exception reporting was also higher.
  • Some mental health indicators were lower than the CCG and national average

We have rated the practice as requires improvement for providing well led services. This is because:

  • Not all staff had received an appraisal in the preceding 12 months.

  • The governance systems in place were not always effective. For example, we found governance issues relating to risk assessments for security and not all staff had received a DBS check prior to commencing employment.

  • Health and safety risk assessments had been undertaken but there was no oversight to ensure actions identified were taken and monitored.

  • There was no formal oversight of nurses working in advanced practice. Some staff were not aware of the practice major incident plans and what their role would be.

  • Processes to ensure competency of staff working in advance practice was not formalised or audited.

  • The arrangements for governance and performance management did not always operate effectively. Oversight of policy reviews and updates had not been planned and we found two different policies for safeguarding and fire. Staff were not able to identify which one they would use.

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 the provider should make improvements in are;

  • Review the process to oversee the accuracy of patient notes summarising.
  • Continue to monitor and update staff training.
  • Continue to monitor and support staff in areas where there is a reduced resource.
  • Continue to monitor and improve cancer screening uptake and exception reporting.
  • Continue to monitor the uptake of childhood immunisations to meet the WHO target of 95%.

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

Rosie Benneyworth

Chief Inspector of PMS and Integrated Care

24 August 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 24 August 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 12 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is still rated as good.

Our key findings were as follows:

  • The systems and processes to systematically record safety alerts had been improved and showed the alerts had been recorded, actions had been taken, and learning shared. This had improved the oversight of safety.
  • Systematic and regular processes to ensure that patients taking high risk medicines were monitored appropriately were in place.
  • Prescription stationary was monitored effectively.
  • The practice had employed an additional 16 hours a week of dispensary staff to ensure the workload delegated to them was manageable and sustainable to ensure the safe management of medicines.
  • All staff who undertook chaperone duties had received training appropriate to the role and a Disclosure and Baring Service (DBS) check.
  • The fire safety risk assessments had been reviewed and all actions were either completed or plans were in place to ensure that patients and staff were kept safe from harm.
  • One of the practice reception team had taken a role as carer’s champion. The practice had systems and processes in place to formalise their knowledge of patients who were carers. There was a display with relevant information for carers in the waiting area. A member of the Suffolk Carers Association attended the practice and was available for patients to speak with.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr R.A.Hutton & Partners also known as Reynard Surgery on 12 January 2017. Overall the practice is rated as good.

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

  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced by the recently formed management team and practice staff.

  • On the day of the inspection the practice was undergoing partnership changes.

  • The practice had strong, visible clinical and managerial leadership. They told us that the practice systems and processes had been improved and that they were working on areas that required further improvements.

  • We found that there was an open and transparent approach to safety and a system was in place for reporting and recording significant events.
  • The practice used a range of assessments to manage the risks to patients but these needed to be improved, some actions identified had not been completed.
  • 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.
  • The practice had engaged with Cancer Research UK to improve and encourage uptake on the national screening programmes.
  • 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 provider was aware of and complied with the requirements of the duty of candour.
  • The practice engaged with the newly formed patient participation group (PPG). To help patients with low mobility or those who used a wheelchair, a member had undertaken a survey of the practice and as a result some changes were made.

Areas of outstanding;

  • The practice employed a retired GP as a clinical co-ordinator. This staff member was responsible for managing the systems and processes to ensure that the practice met the quality and outcomes framework and maintain high quality care for the patients. This staff member was involved in the weekly clinical meetings, writing protocols, supporting the nurse lead for infection control and led on the unplanned admission service for vulnerable people. All the practice staff told us that this post had made a significant improvement to the management of the practice. The practice had clear governance structures to ensure that the partners took any clinical decisions. This staff member had attended training and was developing social prescribing (Social prescribing involves empowering individuals to improve their health and wellbeing and social welfare by connecting them to non-medical and community support services) within the practice. This was to be achieved by engaging with other agencies including voluntary and third sector.

  • The practice demographics included a population of patients whose first language was not English and patients who could be marginalised, for example, from the travelling community. In addition due to the proximity of an airbase, they also looked after a number of patients with dual registration, and a number of retired service personnel. The practice did not have access to the military records of active serving personnel and therefore found this challenging at times to maintain continuity of care.

To help patients access appropriate healthcare they had translated the practice leaflets into the three most common languages, Polish, Lithuanian and Portuguese, including one on ‘How to use the NHS’. Practice staff regularly helped patients who had low literacy to complete forms or to understand information that was in written form. The practice employed a nurse who had experience of working abroad and in the American Red Cross; this gave some ex-military patients and veteran’s confidence to access general health care including services available for those who may be experiencing poor mental health at the practice. The practice distributed food vouchers for the local food bank.

The areas where the provider must make improvement are:

  • Provide systems and processes to systematically record safety alerts to give the management team clear oversight, that alerts have been recorded, actions taken and learning shared.

  • Implement systematic and regular processes to ensure that patients taking high risk medicines are monitored appropriately.

  • Ensure that all staff who undertake chaperone duties receive training appropriate to the role and that a disclosure and baring check or a written risk is undertaken.

  • Ensure that key dispensary staff have capacity to manage the workload delegated to them and can ensure the safe management of medicines.

The areas where the provider should make improvement are:

  • Review the fire safety risk assessment and ensure that all actions are completed and that patients and staff are kept safe from harm.

  • Ensure that prescription stationary is monitored effectively.

  • Review the methods used to identify and record carers to ensure they have the opportunity to access support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice