This practice is rated as Good overall. (Previous rating 10 May 2018 – Good with requires improvement in safe)

The key question at this inspection was rated as:

Are services safe? – Good

We carried out an announced follow up inspection at Beech Tree Medical 5 December 2018. The reason for this inspection was to follow up from a previous inspection on 10 May 2018 when the area of safe had been identified as requiring improvement. The overall rating was good but there had been a breach of Regulation 12 HSCA Regulations 2014: Safe care and treatment. The full comprehensive report on the 10 May 2018 inspection can be found by selecting the ‘all reports’ link for Beech Tree Medical Practice on our website at .

At our inspection on 10 May 2018 we noted one medicine was out of date as the staff member had not been able to locate an expiry date. We also noted that four of the new patient group directions had not been signed by all relevant staff or the authorising person. There were also areas where we stated the provider should make improvements which we noted had been addressed.

At this inspection we found:

• The practice had reviewed a number of systems to manage risk so that safety incidents were less likely to happen. For example, in the checking of emergency medicines, dealing with new patient group directives (PGDs), testing of computer and IT equipment and sepsis training.
• The practice had introduced a system to follow up and record actions taken when children and vulnerable people had not attended for their hospital appointments.
• We noted that two fire drills had taken place and saw evidence to show that the building had been successfully evacuated.
• The practice had reviewed all policies in the practice and made a decision to review these annually.
• We saw evidence of how the practice had ensured that they received assurance from patients using blood self-testing equipment were aware of the need for calibration.
• The practice had continued to add to the carers register and this work was ongoing.

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

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

This practice is rated as Good overall.

(Previous inspection 7 September 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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We undertook a comprehensive inspection of Beech Tree Medical Practice on 7 September 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as requires improvement overall. They were rated as inadequate for providing safe services and required improvement in providing effective and well led services. The practice was required to produce an action plan to detail how they would meet the legal requirements in relation to the breaches in regulations that we identified in the September inspection. The full comprehensive report on the 7 September 2017 inspection can be found by selecting the ‘all reports’ link for Beech Tree Medical Practice on our website at .

We carried out a further announced comprehensive inspection on 10 May 2018 to check that the provider now complied with legal requirements. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

• The practice had a number of 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. However, we noted that whilst there was a system for checking medicines, one medicine was out of date as the staff member had not been able to locate an expiry date. We also noted that four of the new patient group directions had not been signed by all relevant staff or the authorising person.
• The practice had introduced a more effective system for recording significant events and ensured that the lessons learned from these were shared throughout the practice.
• A series of audits had been carried out to review performance.
• 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 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 a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Conduct staff training in recognising and responding to acutely unwell or deteriorating patients who may have sepsis.
• Carry out a formal fire evacuation procedure.
• Ensure results of patients who self-test for anticoagulant therapy are recorded in their records and that equipment being used by patients to monitor their blood coagulation is calibrated.
• Document in the records of those children who have not attended hospital appointments and what action was taken.
• Keep policies under review with appropriate timescales.
• Continue to identify patients and develop the register of carers to provide appropriate support.
• Explore with the CCG the formal arrangements for electrical testing of computer and IT equipment.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beech Tree Medical Practice on 7 September 2017. Overall the practice is rated as requires improvement.

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

• The practice had an open and transparent approach to safety but did not have sufficient effective systems and processes in place to ensure patients were always kept safe. There was a system in place for reporting and recording significant events which staff were aware of, but the practice did not always identify and record all significant events to enable analysis and learning from outcomes.

• The practice did not have systems to minimise risks to patient safety regarding medicines, and safety alerts, but addressed this immediately and carried out retrospective audits and patient reviews to ensure patients were not at risk.

• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. Clinical staff told us they were aware of current evidence based guidance and were able to describe some actions taken using the latest guidance. However, there was no process in place for cascading changes in local and national guidance to clinical staff, to provide evidence of discussion, no formal record reviews or audits relating to changes in NICE guidance.

• Results from the National GP Patient Survey 2017 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment, although results were slightly below the Clinical Commissioning Group (CCG) and national averages.

• 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 said they found it easy to make an appointment and urgent appointments were available the same day.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice had a long established and stable workforce and staff felt supported by management. However, whilst staff were clear regarding the leadership roles in the practice, governance arrangements did not always operate effectively and leaders were not always clear about their roles and accountability for quality.

• The practice had made attempts to seek feedback from patients, but did not have an actual Patient Participation Group (PPG). However, they had introduced a virtual group to achieve patient views and feedback. The practice engaged with staff during staff meetings and during daily discussions but opportunities for formal feedback from clinical staff were limited as staff had not received appraisal for several years.

• 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 must make improvement are:

• To ensure that care and treatment is provided in a safe way to patients.

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

See requirement notices at the end of this report.

The areas where the provider should make improvement are:

• Ensure there are systems in place for recording activity to demonstrate what actions have been taken. For example, regarding, significant events, Legionella, monitoring of prescriptions and capturing patients’ suggestions, comments and verbal complaints,
• Assure themselves that staff have the necessary knowledge and skills regarding the Mental Capacity Act (MCA).
• Introduce measures to provide assurance that evidence based guidelines are being followed.
• Ensure more easily visible information is available for patients regarding the complaints procedure and the availability of the interpreting service.
• Take more action to promote and develop the PPG.
• Introduce a process to ensure clinical input prior to destruction of uncollected prescriptions with regular monitoring.
• Take action to identify more patients as carers.
• Ensure that triaging of hospital letters by trained non-clinical staff is audited and supervised.
• Introduce and monitor a formal plan of audit to promote audit activity within the practice.
• Develop an effective system to identify vulnerable adults and ensure they are entered on the safeguarding register as well as children of concern and review A&E attendances of these patients along with the review of children on the at risk register who frequently attend A&E.
• Review the findings of the national GP patient survey to address areas where results are below the national average.
• Establish a system of maintaining the Hepatitis B status for all clinical staff.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice