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Archived: The Bermuda Practice Partnership Good

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Reports


Inspection carried out on 15 December 2020

During an inspection looking at part of the service

In light of the current Covid-19, The Care Quality Commissions (CQC) has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices, by minimising the time inspection teams spend on site.

In order to seek assurances around potential risks to patients, we carried out a GP Focused Inspection Pilot (GPFIP) of The Bermuda Practice Partnership between 12 December 2020 and the 15 December 2020 to follow up on information of concern raised to CQC.

This report covers our findings in relation to those concerns. The inspection consisted of remote interviews and reviews of clinical records which were conducted with the consent of the provider. We focussed our inspection on the following key questions; Safe, Effective and Well-Led. We did not inspect the Caring or Responsive key questions as part of this inspection.

We have not rated the practice during this inspection as we did not visit the Provider.

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 found that:

  • The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • The practice did not have systems for the appropriate and safe use of medicines, including medicines optimisation
  • The delivery of care and treatment was exposing patients to the risk of harm. This included evidence of actual or potential actual harm for patients.
  • Patients’ needs were not assessed, and care and treatment was not delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • Responsibilities and roles were unclear and the overall governance arrangements were ineffective.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure patients are protected from abuse and improper treatment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Following our remote GP focused inspection pilot undertaken on 12, 13 and 15 December 2020, we issued the provider with an urgent notice of decision to impose conditions on the registration.

In line with CQC enforcement procedures, the provider is expected to implement actions to address all the issues raised within agreed timescales. The service will be kept under review and if needed could be escalated to further urgent enforcement action.

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 General Practice

Review carried out on 22 January 2020

During an annual regulatory review

We reviewed the information available to us about The Bermuda Practice Partnership on 22 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 22 March 2019

During an inspection looking at part of the service

This practice is rated as Good overall. (Previous rating June 2018 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

We carried out an announced focused inspection at The Bermuda Partnership Practice on 22 March 2019, to follow up on recommendations made at our previous inspection in April 2018 (report published June 2018).

Areas for improvement found at the previous inspection were:

  • Reviewing the fire safety risk assessment to resolve any actions which had not been completed.
  • Reviewing the arrangements for identifying and registering patients who are also carers
  • Reviewing arrangements for summarising new patient care records onto the practice systems.
  • Reviewing the effectiveness of arrangements for the security of prescription stationery, to ensure it was appropriately logged and tracked.

We inspected the safe domain only and reviewed arrangements for identifying patients who were also carers.

At this inspection we found:

  • Outstanding actions from the fire risk assessment had been completed.
  • Systems and processes were in place to identify patients who were carers and also patients who were cared for. The practice had linked their carers list with the frailty list and had identified 5% of their practice population as carers, or patients who were cared for.
  • Progress had been made on summarising patient records. The practice had a designated member of staff who was responsible for this task and we saw that summarising of records was up to date.
  • The practice had strengthened the system for monitoring and logging prescription stationery and it was clear when, where and who had used prescription stationery. When prescription stationery was not in use it was securely stored.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 10/04/2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection November 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Bermuda Practice Partnership on 10 April 2018. This inspection was conducted to follow up on a breach of regulation that was found in the previous inspection, which were related to the safe and well led domains.

At this inspection we found:

  • The practice had made improvements since the last inspection including the signing and authorising of all patient group directives for immunisations; the correct and safe disposal of cytotoxic drugs (cytotoxic drugs are medicines that contain chemicals that are toxic to cells); practice policies, such as for infection control, were now being followed; and all single-use items that were seen during inspection were now within their expiration date and safe to use.
  • The practice had recruited a new practice manager who had been in post since February 2018.
  • The practice continued to use a self-help internet and mobile application on a daily basis and was being developed further to help those with substance misuse, and patients with frailty.
  • The practice had introduced an additional self-help initiative for patients with new babies and young children, which contained information and self-management advice on illnesses and conditions that may affect small children and young babies.
  • The practice had introduced weekly meetings for all staff, partners and clinicians to share learning from complaints and significant events, changes in the practice were communicated and feedback from patients was provided.
  • The practice had improved their uptake for cervical screening to be in line with the national average.
  • 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. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • 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.
  • There was focus on continuous learning and improvement at all levels of the organisation.
  • However actions needed as identified in a fire risk assessment carried out in May 2017 had not all been completed. As a result we made a referral to the local fire safety service.

The areas where the provider should make improvements are:

  • Review the fire safety risk assessment to resolve any actions not yet completed.
  • Review arrangements for identifying and registering patients who are also carers.

  • Review arrangements for summarising new patient care records onto the practice systems.
  • Review how effectiveness of the new arrangements for the security of prescription pads, such as the recording of script serial numbers.

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

Inspection carried out on 16 November 2017

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 Bermuda Practice Partnership on 5 July 2016. The overall rating for the practice was requires improvement. We carried out a follow up focused inspection on 20 April 2017 to assess if the practice met the legal requirements in relation to the breaches in regulation previously identified. Whilst some improvements had been made, the overall rating for the practice remained requires improvement as the practice had not met all the legal requirements. The full comprehensive and follow up report on the July 2016 and April 2017 inspections can be found by selecting the ‘all reports’ link for The Bermuda Practice Partnership on our website at www.cqc.org.uk. 

This inspection was a focused follow up carried out on 16 November 2017 to confirm that the practice met the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 20 April 2017. This report covers our findings in relation to those requirements and any additional improvements made since our last inspection.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

  • The practice’s systems did not ensure that policies and procedures were always followed.
  • Not all patient group directions were countersigned by an authorised person; not all single use equipment available was in date and cytotoxic drugs were not disposed of in the correct containers.
  • Vaccines were in date, however staff did not always follow procedures to document that stock rotation had been completed. For example, the checklist documenting the expiry dates of medicines had not been updated once stock had been changed.
  • The practice had emergency equipment and medicines on site which were kept in a room with a coded keypad on the door however not all staff were aware of the code and so would not be able to easily access the equipment or medicines in the event of an emergency 
  • The practice’s cleaning schedule checklist was not completed which meant the practice could not evidence that the cleaning schedules had been completed.
  • There were comprehensive risk assessments in relation to safety issues such as fire and legionnaires disease. However, a fire risk assessment had been undertaken in May 2017 and there were still actions which had not been addressed.
  • There was an improved oversight of the governance for training to ensure all staff had training at the right time. Staff had all received training for their roles and mandatory training was now included on the practice’s induction checklist for new starters.
  • The practice had launched a self-care internet and mobile application solution which aimed to help patients better manage long-term conditions and encourage healthy lifestyles by providing easily accessible information.

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

Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

In addition the provider should:

  • Review the processes for the care of patients with long-term conditions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 20 April 2017

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 Bermuda Practice Partnership on 5 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 5 July 2016 inspection can be found by selecting the ‘all reports’ link for The Bermuda Practice Partnership on our website at www.cqc.org.uk.

On the previous inspection we rated the practice as requires improvement on four of the five domains (safe, effective, responsive and well-led). The practice was rated as good for caring. We rated the practice as requires improvement for providing safe services as the practices storage of emergency medicines was accessible to unauthorised personnel and storage of prescription forms and pads were not fully monitored. The practice was rated as requires improvements for providing effective care as there were shortfalls in the monitoring of clinical audits and patient outcomes. We identified the practice to not be responsive to some of their patient population group and had limitations in learning from complaints. The practice had some governance structures in place but had shortfalls in monitoring staff training and recruitment and this lead to them being rated as requires improvement in well led.

This inspection was a focused inspection carried out on the 20 April 2017, to assess 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 5 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

On this inspection we have rated four of five key questions: responsive as good, safe, effective and well-led as requires improvement. Overall the practice remains rated as requires improvement.

Our key findings were as follows:

  • The practice had not achieved all the shortfalls of the last inspection. In particular the practice had changed monitoring of staff training and developed a training schedule for 2017 as a way of monitoring that staff had received the required training for their role. However, not all staff had completed safeguarding adult or children training or basic life support at the time of follow up inspection.

  • Complaints were monitored and discussed at team meetings with actions identified and recorded in a complaints log. However the practice did not engage in a review of complaints to identify trend analysis and emerging themes.

  • The practice had improved the security of prescriptions and emergency equipment by removing emergency equipment from patient accessible areas and placing keypad locks on clinical and treatment room doors.

  • The practice had amended the way significant events were reported and added significant events as standing agenda items at meetings to ensure learning was disseminated to staff members.

  • Clinical audits were undertaken and reviewed to monitor outcomes. Findings were discussed at clinical meetings.

  • The practice monitored and increased patient outcomes such as improving the uptake of cervical screening to be in line with national averages. The practice had also developed care plans and treatment reviews for patients with long-term conditions.

  • The practice made sure there were two previous employer references for any new employee starting at the practice.

  • An information booklet had been created for patients or carers who were ex-military which signposted to local and national support groups.

There were areas of practice where the provider continued to need to make improvements.

Importantly, the provider must:

  • Ensure all staff have received training appropriate to their role especially for the area of safeguarding adults and children and basic life support.

In addition the provider should:

  • Consider undertaking a trend analysis of complaints received in order to identify similarities in complaints and implement changes to practice as a result of emerging themes.

  • Continue to review arrangements for identifying patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 5 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bermuda Practice Partnership on 5 July 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.
  • Not all staff had received training appropriate for their role; this included safeguarding adults and children.
  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and the security of blank prescription forms.
  • Data showed patient outcomes were low compared to the national average, but there were some areas where information was used to make improvements. For example, the practice completed a review of patients with Chronic Obstructive Pulmonary Disorder (COPD) which is a chronic lung condition. They found that patients had poor management of their condition and those that did manage it often did not come in for reviews. The practice also identified that patients were often stepped up in their treatment but not stepped down. As a result of the audit the practice reviewed how patients were categorised and created a new category system coded by severity of the condition. A template was designed so that monitoring could be better tracked and records updated accordingly. The practice had also allocated a named doctor and nurse to lead on COPD and to allow for better monitoring of patients with this condition and to review medicines optimisation strategies.
  • Clinical audits were carried out, but there was limited evidence that audits were driving improvements to patient outcomes.
  • Patients said they were treated with compassion, dignity and respect.
  • Information about services was available, the practice were able to access leaflets in other languages via on line translation service.

The areas where the provider must make improvements are:

  • Ensure all staff have received training appropriate to their role.

  • Ensure lessons learnt from complaints and significant events are shared consistently with relevant members of staff and outcomes are monitored.

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

  • Ensure the process for monitoring the use of prescription forms and pads is safe and effective.

  • Ensure emergency medicines are stored away from areas where members of the public can access them.

In addition the provider should:

  • Continue to review arrangements for identifying patients who are also carers.

  • Continue to review actions taken to improve the care and support for patients’ wellbeing including for long term conditions.

  • Review arrangements to promote cervical screening uptake.

  • Review arrangements for identifying ex-military personnel.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 14 October 2013

During a routine inspection

The Bermuda Practice Partnership shares a purpose built building with Shakespeare House Medical Centre. Over the last 12-18 months they have merged to become The Bermuda and Marlowe Practice. Patients from both sites now have access to the full range of services.

On the day of our visit to The Bermuda Practice Partnership we met with the practice manager and two of the GP partners. We spoke with seven patients and with five members of practice staff.

Patients told us that they were treated with dignity and respect. One patient said "When you make an appointment the staff ask you appropriate questions which helps identify the right appointment for you".

Most patients were happy with the care and treatment they received. One patient said "I have been a patient here for years and they always provide a great service". Two of the patients we spoke with were not happy with the length of time they had to wait before their appointment. One patient said "waiting for your appointment is sometimes frustrating. The reception staff don�t tell us when the GPs or nurses are running late".

Patients were protected from the risk and spread of infection because appropriate guidance had been followed. The practice was clean and hygienic.

Staff felt supported in their roles. We found that staff had received training and appraisals. One person told us �I really feel supported by the team, practice manager and the GPs�.

Patient views were sought and their responses were acted upon. The practice ensured appropriate management and processes were in place to protect the safety and welfare of their patients.

There was an effective complaints process. This was well advertised to patients in the practice leaflet and in the waiting room. Some patients told us that they had not needed to make a complaint but felt confident that the practice would address any issues they had appropriately. Two patients explained that they had raised a complaint in the past with the practice and were satisfied with the action taken.