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St Lukes Surgery Requires improvement Also known as St Luke's and Botley Surgeries

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 October 2018

This practice is rated as requires improvement overall. (Previous rating February 2018 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at St Lukes Surgery on 21/08/2018 to follow up on breaches of regulations. The practice had previously been inspected in February 2018, when it was rated Inadequate overall. Specifically, the practice was rated as inadequate for providing safe, effective, responsive and well-led services. The practice had been rated as good for providing caring services. The practice was placed in special measures.

At this inspection we found:

  • There was a new approach to the running of the practice with an open and transparent approach to safety and an effective system in place for reviewing and recording areas for improvement.
  • The practice was in the process of merging with another GP practice, the Living Well Partnership. The practice had commenced the merger with the Living Well Partnership in October 2017 to promote sustainability and to share services for patients. We found that the merger of shared systems and processes had almost been completed.
  • Senior managers had assumed responsibility for overseeing different areas of governance and leadership and had implemented an organisation hierarchy of line management and accountability.
  • The practice had implemented 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.
  • There were gaps in staff training and not all staff had received an annual appraisal.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patient feedback regarding the ease of accessing care remained mixed. The practice had made some changes to improve access for patients but new systems were not embedded.
  • Staff reported feeling well supported by leaders and there was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out duties.
  • 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:

  • Continue to review prescribing for some less recommended antibiotics to reduce the number of items prescribed, in line with local and national averages.
  • Review processes which enable staff to access policies and procedures.
  • Review registration to reflect changes made to the provider and partners.

This service was placed in special measures in February 2018. Sufficient improvements have been made such that St Lukes Surgery has now been rated as Requires Improvement. I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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

Inspection areas

Safe

Good

Updated 19 October 2018

We rated the practice as good for providing safe services.

At our February 2018 inspection we rated the practice as inadequate for providing safe services.

The practice was rated as inadequate for providing safe services because:

  • Not all staff had completed training required to undertake their role and the knowledge required to keep patients safe. This included for infection control, safeguarding adult and children and fire safety training.
  • Infection control processes were not effective. There was no risk assessment or action plan in place to identified how concerns raised in the infection control audit were to be addressed.
  • Not all emergency medicines were stored in line with policies or processes. Some medical equipment had passed their expiration dates.

At this inspection we found that processes had significantly improved and the practice had implemented systems to address all issues identified.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. All staff knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a DBS check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control. The practice had undertaken an external audit in April 2018 and had completed all subsequent recommendations and actions.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was now an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance.
  • Prescribing for some broad-spectrum antibiotics was higher than local and national averages. The practice had reviewed its antibiotic prescribing and had taken some action to support good antimicrobial stewardship. Prescribing for hypnotics (medicines to treat anxiety and sleep disorders) was in line with local and national averages.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were now adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.

Effective

Requires improvement

Updated 19 October 2018

We rated the practice as requires improvement for providing effective services overall and across all population groups.

At our previous inspection on 12 February 2018 we rated the practice as inadequate for providing effective services overall and across all population groups.

The practice was rated as inadequate for providing effective services because:

  • There had been a notable staff turnover creating a number of vacancies including nursing roles and managerial or leadership positions.
  • There was a lack of oversight and monitoring of data collected through the Quality and Outcome Framework (QOF) reporting system. There was a high level of exception reporting of patients with long term conditions and a lack of explanation for this.

At this inspection we found that the practice had made significant improvements. However, the practice is rated as requires improvement because:

  • The majority of staff, with the exception of two clinicians, had not received an appraisal within the last 12 months.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of their medicines.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.
  • The practice had recruited a respiratory nurse who had undertaken weekly clinics for patients with asthma and chronic obstructive pulmonary disease (COPD) since July 2018.

Families, children and young people:

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • Childhood immunisation uptake rates were in line or above with the target percentage of 90% or above.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

Working age people (including those recently retired and students):

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • The practice’s uptake for cervical screening was 80%, which was in line with the 80% coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was in line with the national average.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

This population group was rated requires improvement for effective because the requires improvement rating for effective affects all population groups.

There were however areas of good practice:

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medicines.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice had received ‘dementia friendly’ accreditation. All staff had received dementia awareness training and the practice had improved signage throughout the practice and branch site to improve accessibility for patients with dementia.
  • The practice offered annual health checks to patients with a learning disability.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • Overall exception reporting was in line with local and national averages. However, the practice’s exception reporting results for some indicators relating to long-term conditions were higher than local and national averages. Senior managers were aware of this and had recruited a performance lead in March 2018 and a performance administrator in May 2018 to oversee the system of recalling patients who had long term conditions for relevant health checks. The practice had undertaken an audit of exception reporting results in August 2018 and found an improvement in exception reporting in nine clinical areas that had been higher than local and national averages.
  • Exception reporting figures for mental health were in line with national and local averages.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles, however, not all staff had received appraisals within the last 12 months.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date. However, the practice did not have a system to monitor this.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, coaching and mentoring, clinical supervision and revalidation. Two out of nine clinicians had received an appraisal within the last 12 months. None of the administration staff had received an appraisal within the last 12 months. The practice had not scheduled dates to complete staff appraisals. Since our last inspection the practice had reviewed the appraisal form and line managers had undertaken appraisal training. The practice told us they planned to complete appraisals for all staff by November 2018.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 19 October 2018

At our last inspection we rated the practice as good for caring. The practice remains rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • We observed that patients were treated with kindness and respect.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given).

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • Data captured from the GP patient survey was comparable to local and national averages.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Requires improvement

Updated 19 October 2018

We rated the practice as requires improvement for providing effective services overall and across all population groups.

At our February 2018 inspection we rated the practice, and all of the population groups, as inadequate for providing responsive services.

The practice was rated as inadequate for responsive because:

  • There was a lack of evidence to demonstrate action taken in response to low GP patient survey scores.
  • Patients complaints were recorded but there was not always evidence of patients having received a response to their complaint or a documented outcome around learning. The practice undertook a trend analysis of complaints but showed little evidence as to how they would address these issues.
  • Asthma reviews were being undertaken via the telephone and patients only called in for a face to face appointment if deemed unwell or not in control of their Asthma. There was no risk assessment or action plan to ensure all patients had received their routine reviews.

At this inspection we found that some improvements had been made however the practice was rated as requires improvement for providing responsive services because;

  • Patients continued to experience difficulty when accessing the practice via telephone and accessing routine appointments.
  • Actions taken to improve patient feedback were not fully embedded.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences. However, there were shortfalls in patients accessing the practice by phone and accessing routine appointments.

  • The practice understood the needs of its population and tailored services in response to those needs. The practice was aware that GP survey results were lower that local and national averages and had created an action plan to improve access to routine appointments. Since our last inspection in April 2018, the practice had sourced a regular locum GP who was due to begin providing consultations in August 2018, and had appointed a practice nurse in August 2018. The practice told us they planned to improve telephone access by merging telephone systems with the Living Well Partnership but this had not been implemented at the time of inspection.
  • GP partners from the Living Well Partnership provided consultations at the practice during busy times and the practice was proactively recruiting to fill vacant clinical positions. However, structural changes were still in their infancy and patient feedback did not reflect improved access to routine appointments and access to the practice via the telephone.
  • The practice had recently offered patients an online consultation service with an independent provider who had been contracted to provided 40 appointments per week for patients registered at the practice. The practice reviewed patient feedback from this provider which was positive.
  • The practice had employed a respiratory nurse who undertook clinics for patients with asthma and chronic obstructive pulmonary disease.
  • Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice engaged in a care navigator service with a dedicated care navigator allocated to the practice. This person was able to visit elderly patients at home, including during weekends and offer signposting to local support groups or agencies.
  • The practice had provided the nursing homes with an emergency contact number for the practice to bypass the main telephone system.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.

People with long-term conditions:

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours and Saturday appointments.
  • E-consultations services were available.
  • Appointments were only available from 8am to 6.30pm. Extended hours appointments were available through the Eastleigh Southern Parishes Network (which the practice was part of). Patients could request an extended hours appointment by contacting the practice.

People whose circumstances make them vulnerable:

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

This population group was rated requires improvement for effective because the requires improvement rating for effective and responsive affects all population groups.

There were however areas of good practice:

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia. Patients who failed to attend were proactively followed up by a phone call from a GP.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs. However, patient feedback reflected delays for routine appointments.

  • We saw that the practice provided enough GP and nurse practitioner consultations to meet the population of the patient list through the use of locums and support from the Living Well Partnership GP partners. However the practice was still actively recruiting to fill GP and practice nurse vacancies. The practice had recently secured a regular GP locum who was due to commence support in August 2018 and a practice nurse had been appointed on the day of inspection.
  • Patients told us they experienced difficulty accessing the practice by phone which was reflected in GP patient survey results and NHS choices. Patient Survey 2018 results showed that patient satisfaction had not improved. Senior managers were aware of this and told us that they were planning to implement urgent care clinics for patients at the practice which would include telephone calls being triaged centrally across the Living Well Partnership.
  • At our last inspection, data from the GP patient survey showed that the amount of people who would recommend others to the practice was lower than local and national averages. Data provided by the practice showed this was an improving picture. Since the last inspection the practice had undertaken a review of the feedback collected in the friends and family test as well as the 2017 GP patient survey results. From this review the practice had identified key themes as learning points and documented what actions they had taken to address these concerns. For example, the practice had identified that one of the main reasons for patients not recommending the practice was due to a lack of routine appointments available to patients. In response the practice had continued to focus on the recruitment of clinical staff and had recruited a respiratory nurse, sourced a regular locum GP and appointed a practice nurse in August 2018.
  • Patients with the most urgent needs had their care and treatment prioritised. Patients reported that they were always seen if they had an urgent need.

Listening and learning from concerns and complaints

The practice had revised its complaints system. It took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • At our last inspection in February 2018 we found that patient’s complaints were recorded but there was not always evidence of patients having received a response to their complaint or a documented outcome around learning. The practice undertook a trend analysis of complaints but showed little evidence as to how they would address these issues. At this inspection we found that the practice had responded appropriately to complaints. Learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 19 October 2018

We rated the practice as good for providing a well-led service.

At our February 2018 inspection we rated the practice, and all of the population groups, as inadequate for providing well-led services.

The practice was rated as inadequate for well-led because:

  • Systems and processes were not in place or if present were not fully embedded into practice in a way that kept staff and patients safe. This included monitoring of risk assessments such as fire safety and health and safety. Not all actions from risk assessments had been identified, completed or documented progress.
  • There was a lack of leadership and key vacancies within the leadership team.
  • There was a focus on identifying patient need by collecting feedback through patient surveys however, there was limited progress on developing areas identified in patient feedback and limited involvement through working with the patient participation group.
  • There was a lack of oversight and monitoring of systems and processes to prevent data protection breaches.
  • The process for monitoring and recording staff induction during their probation period was not embedded into practice. Documents reviewed were incomplete and unable to evidence that staff had received the relevant training for their role.

At this inspection we found that the practice had made significant improvements and addressed issues identified. A new organisational structure had been implemented. Senior managers had were accountable for all areas of governance and performance. However, some systems required fully embedding. For example staff did not always have immediate access all policies and procedures

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • The practice was in the process of merging with another GP practice, the Living Well Partnership. GP partners from the Living Well Partnership were named, as well as the two GP partners at the practice, on the contract held with the Clinical Commissioning Group for being responsible for delivering services to patients. The merger was not reflected in the registration of the location, provider and partners. Senior managers had assumed responsibility for overseeing different areas of governance and leadership and had implemented an organisation hierarchy of line management and responsibility.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. Following our inspection in February 2018, senior managers had implemented an action plan to address all issues identified. We saw that all actions had either been completed or were in progress and on track to meet the specified completion date.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.
  • The practice had successfully appointed a nurse practitioner and a reception and site lead at the practice, and a nursing services lead across the Living Well Partnership. Two regular locum GPs and a locum respiratory nurse had been sourced and the practice had recommenced weekly clinics for patients with asthma and chronic obstructive pulmonary disease (COPD, a long-term lung condition).

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. Staff told us that since our last inspection morale had improved and stress and workload had decreased. Staff understood the responsibilities of senior managers of the new organisational structure and told us they had seen improvements implemented. For example, regular monthly meetings, visible line managers and weekly notifications regarding changes.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. Staff were supported to meet the requirements of professional revalidation where necessary. However, there were shortfalls in the delivery of annual appraisals for staff. The practice told us managers had received training to undertake appraisals for all staff and aimed to complete this by November 2018.
  • There was a strong emphasis on the safety and well-being of all staff. The practice had completed health and safety and environmental audits and had subsequently completed or were in the process of completing all relevant actions within the required time frames.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • At our last inspection in February 2018 we found that systems and processes were not in place or if present were not fully embedded into practice in a way that kept staff and patients safe. This included monitoring of risk assessments such as fire safety and health and safety. Not all actions from risk assessments had been identified, completed or documented progress. At this inspection saw that all systems and processes were in place, for example, all risk assessments had been undertaken, completed or documented progress. However, some systems required further embedding. For example, practice staff were not able to access all policies and procedures electronically, however, they did have access to paper copies.
  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • At our last inspection we found that the process for monitoring and recording staff induction during their probation period was not embedded into practice. At this inspection we saw that induction documents were complete and evidenced that staff had received the relevant training for their role. The practice had an overview system of mandatory training which indicated when refresher training was due to be completed. However, the overview system did not include specialist training for nurses. We discussed this with the practice who had subsequently updated the overview of staff training to include nurse specialist training.

Managing risks, issues and performance

There were clear processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. For example, the practice had implemented positive changes to the process for recalling patients with long-term conditions to annual health checks, following audits of performance.
  • Performance information was combined with the views of patients. The practice was aware of patient dissatisfaction regarding access to routine appointments and via the telephone and had implemented changes to improve access. For example, the practice had implemented an online consultation services, recruited staff and sub-contracted some services to another site owned by the Living Well Partnership. However, those recent changes had not been reflected in patient feedback on the day of inspection, which was in line with GP patient survey results and the practice’s analysis of friends and family and NHS choices feedback.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. At our last inspection in February 2018, we found that the practice was investigating a serious data protection breach whereby patients’ private email addresses were circulated to the patient reference group in January 2018. At this inspection we found that the breach had been investigated and concluded. We saw that the practice had apologised to patients in line with their duty of candour policy and procedure.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement