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Inspection carried out on 2 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Central Dales Practice on 31 March 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Central Dales Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 2 October 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 31 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance.
  • Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was mostly above local CCG averages and above national averages.
  • 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.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

Implement regular checks of dispensary stock to ensure it is within expiry date and maintain appropriate records.

Review procedures to ensure fridge temperatures are recorded daily in line with national guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 31 March 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Central Dales Practice on 1 June 2015. Overall the rating for the practice was requires improvement (The domains of safe, effective and well led were rated as requires improvement, and caring and responsive as good).

In particular, on 1 June 2015, we found the following areas of concern:

  • Systems, processes and practices were not always reliable or appropriate to ensure patients were kept safe, in particular in respect of the management of medicines and ensuring that non-clinical staff who acted as a chaperone had a DBS check in place.
  • Not all staff had completed mandatory training such as safeguarding and infection control. There were some gaps in the management and support arrangements for staff.
  • The outcome of patients care and treatment was not always monitored regularly or robustly. Few completed clinical audits were carried out and participation in local audits and benchmarking was limited. The results of monitoring were not always used effectively to improve quality.
  • The vision and values for the practice were not well developed.
  • The governance arrangements were not always effective resulting in risks and issues not being identified and or addressed.
  • We had some concern regarding the leadership at the practice. There were concerns with the culture and governance at the practice.

As a result of our findings at this inspection we issued the provider with a requirement notice for the proper and safe management of medicines.

Following the inspection on 1 June 2015 the practice sent us an action plan that explained what actions they would take to meet the regulation in relation to the breach of regulation we identified.

We carried out a further comprehensive inspection at Central Dales Practice on 31 March 2017 to check whether the practice had made the required improvements. We found that some but not all improvements had been made in respect of medicines management. However, we identified further concerns in respect of medicines management. We also found that some areas we identified at the previous inspection that should be improved had not been addressed.

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

  • The practice had failed to ensure that risks to patients were minimised. Areas of concern related to the reporting and investigation of significant events, medicine management, infection prevention and control (IPC) management, safe storage of patient records and medicines within the dispensary and the safe recruitment of staff.
  • Data showed that the practice was performing highly when compared to practices nationally. Clinical audits demonstrated quality improvement.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • The practice demonstrated innovative community engagement.
  • Staff had completed a wide range of qualifications to support them in their role. However, the practice could not demonstrate how they always ensured mandatory training and updating for relevant staff. For example, we reviewed the training record made available to us which showed not all staff were up to date with mandatory training such as infection control, information governance and basic life support.
  • Data from the national GP patient survey showed patients rated the practice higher than others for all aspects of care. Patients told us they were treated with kindness and respect. Patients described being well cared for by an excellent staff team.
  • The practice understood its population profile and had used this understanding to meet the needs of its population.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had a clear vision to deliver high quality care and promote good outcomes for patients.
  • Staff were supported and encouraged to develop new skills and into new roles.
  • The practice encouraged and valued feedback from patients and staff
  • Although the practice had a wide ranging governance framework and staff were, in the majority of cases, aware of roles and responsibilities within the practice; there was insufficient attention paid to identifying, recording and managing risks. The governance arrangements were ineffective which undermined the practice’s aim to provide consistently high quality safe care.
  • The practice’s approach to continuous improvement was mixed. We saw evidence of a focus on continuous learning and improvement in some but not in all areas of the practice. A comprehensive understanding of the performance of the practice was not maintained in all areas and the practice had not addressed all the areas we identified at the previous inspection.

The areas where the provider must make improvement are:

  • Ensure medicines are always managed safely.
  • Introduce reliable processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
  • Address identified concerns with infection prevention and control practice.
  • Ensure recruitment arrangements always include all necessary employment checks for all staff.
  • Ensure all staff are aware of their responsibilities to raise safeguarding concerns.
  • Ensure patient records are securely stored.
  • Take action to address gaps in the mandatory training completed by staff.
  • Review the arrangements for managing concerns regarding staff competence.
  • Implement and embed stronger governance arrangements to enable the provider to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 1 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Central Dales Practice on 1 June 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be good for caring and responsive. It required improvement for safe, effective and for being well led. It also required improvement for providing services for all the population groups.

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

  • There were enough staff to keep patients safe.
  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses.
  • Patient’s needs were assessed and care was planned and delivered in line with current legislation.
  • The needs of the practice population were understood and systems were in place to address identified needs in the way services were delivered.
  • Data showed patients rated the practice higher than others for several aspects of care. Patients were complimentary about the care they received.
  • Patients told us the experience of making an appointment was positive and could access appointments when needed.
  • The practice encouraged patient and staff feedback and demonstrated it acted on this. There was evidence of improvement action being taken in many areas.
  • Staff worked with multidisciplinary teams.
  • There were some gaps in management and support arrangements for staff.
  • The outcome of patients care and treatment was not always monitored regularly or robustly. Few completed clinical audits were carried out and participation in local audits and benchmarking was limited. The results of monitoring were not always used effectively to improve quality. The lack of governance arrangements had resulted in areas such as medicines management not being identified as a risk.
  • Medicines were not always safely managed.
  • The vision and values for the practice were not well developed.
  • We had some concern regarding the leadership at the practice.

We saw several areas of outstanding practice including:

  • The practice offered an unfunded service to a local extra care housing scheme by visiting weekly and delivering medicines to older people that lived there.

  • The practice offered a medicine drop off service at set locations.

  • The practice offered additional pre-bookable appointments on a Tuesday to coincide with various events that took place in the area.

The areas where the provider must make improvements are:

  • Ensure the proper and safe management of medicines. Staff must follow policies and procedures in line with current guidance and legislation in respect of the storage, disposal, dispensing and administration of medicines.

In addition the provider should:

  • Ensure systems are in place so that all staff have completed relevant mandatory training.
  • Ensure governance systems are in place to monitor quality and identify risk.
  • Ensure a programme of clinical audit is in place.
  • Ensure results of audits are monitored and used effectively to improve quality and deliver improvement.
  • Ensure that non-clinical staff have a criminal records check from the Disclosure and Barring Service if they act as a chaperone.
  • Ensure systems are in place for the Control of Substances Hazardous to Health (COSHH)

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice