We carried out an announced comprehensive inspection at Balance Street Practice on 19 February 2019. The announced inspection was part of our inspection programme.

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

• What we found when we inspected
• Information from our ongoing monitoring of data about services and
• Information from the provider, patients, the public and other organisations

We have rated this practice as Good overall.

We rated the practice as requires improvement for providing safe services because:

• The systems, processes and practice that helped to keep patients safe and safeguarded from abuse were insufficient. Not all staff had been in receipt of safeguard training to the level appropriate for their role.
• There were gaps in the process for monitoring patients’ health in relation to the use of high risk medicines.

We rated the practice as good for providing effective services because:

• 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.

We rated the practice as good for providing a caring service because:

• Patients reportedly positively on being treated with care and concern and had confidence and trust in the healthcare professional they saw or spoke to.
• The practice National GP Survey results were above the local clinical commissioning group and England averages. However, improvement in the carer register numbers was required as only 97 registered patients were electronically coded as being a carer which represented 0.7% of the practice population.

We rated the practice as good for providing a responsive service because:

• The practice organised and delivered services to meet patients’ needs.
• The practice National GP survey findings were in line with or above the local clinical commissioning group and England averages in respect of patient access.

We rated the practice as good for providing a well led service because:

• The practice had developed an action plan to meet the needs of its registered population whilst bearing in mind the aims and objectives of the wider health economy.
• Identified gaps in the practice governance processes had been proactively managed to reduce risk and to develop sustainable care. However, some policies we reviewed required clinical oversight and were overdue a review.

These areas affected all population groups, so we rated all population groups as good, except for families, children and young people which was rated requires improvement in effective and therefore rated as requires improvement overall.

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

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Implement safeguard policy updates in line with local and national guidance changes.
• Develop the staff training matrix which enables clear oversight on all staff training.
• Continue to improve the practice carer register numbers.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We inspected this service on 3 October 2014 as part of our new comprehensive inspection programme.

The overall rating for this service is good. We found the practice to be good in the safe, effective, caring, responsive and well-led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health. 

Our key findings were as follows:

• Patients were kept safe because there were arrangements in place for staff to report and learn from key safety risks. The practice had a system in place for reporting, recording and monitoring significant events over time.
• There were systems in place to keep patients safe from the risk and spread of infection.
• Evidence we reviewed demonstrated that patients were satisfied with how they were treated and that this was with compassion, dignity and respect. It also demonstrated that the GPs were good at listening to patients and gave them enough time.
• The practice had an open culture that was effective and encouraged staff to share their views through staff meetings and significant event meetings. 

We saw several areas of outstanding practice including:

• The practice operated a one family one doctor policy, ensuring that every patient had a named GP, and family members were cared for by the same GP. 
• Excellent levels of communication between the GPs facilitated through the informal daily pre morning surgery meetings. 

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

The provider should:

• Maintain a log of medicines alerts, medical devices alerts and other patient safety alerts received which details any action taken, if required.  
• Have a designated infection control lead and carry out internal infection control audits. 
• Carry out a risk assessment and a mercury spillage kit should be available to keep patients and staff safe in the event of a mercury spillage.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out this inspection to follow up on three areas of non-compliance from our previous inspection. During the inspection we spoke with staff, checked equipment and looked at records relating to safety checks and staff recruitment and training.

Staff had received additional training on safeguarding children and vulnerable adults, and were able to accurately describe the safeguarding procedures they would follow. Contact details for external agencies were available in reception and consulting / treatment rooms. Information informing patients that chaperones were available to accompany them was on display in the reception area and waiting rooms.

Temperature sensitive medication was stored appropriately in the dispensary and checks were in place that ensured the refrigerator temperatures were within the safe range. A system had been introduced to check the temperature of the medication refrigerators used for the storage of vaccines. However the temperature of the refrigerators had not been observed and recorded consistently.

We saw that Disclosure and Barring Service checks had been completed on all members of staff, including clinicians, reception and administration staff and dispensary staff. All nurses were registered with their professional body and had indemnity insurance in place.

On the day of our inspection we spoke with eight patients and ten members of staff. Prior to the inspection we spoke with a spokesperson from the patient participation group (PPG) who was also a patient. One patient told us, “I am extremely happy with the surgery. My GP is superb and the service is terrific”. Another patient told us, “The reception staff are very good and helpful and it is easy to get an appointment. The GP is absolutely brilliant. He really listens to me”.

We saw that patients experienced care and treatment that met their needs and that they were supported to bring complaints to the attention of the provider. Comments and complaints patients made were responded to appropriately.

Staff recruitment and selection processes were in place but appropriate checks were not always undertaken before staff began to work at the practice to ensure that they were suitable to work with children and vulnerable adults. We saw that the provider did not always follow its own policy to protect patients from the risk of abuse.

The provider had its own dispensary for patients who lived over one mile away from the practice. We saw that patients were not protected against the risks associated with medicines because the provider did not have effective arrangements in place to store temperature sensitive medicines safely.