We carried out an announced comprehensive inspection at Brunel Medical Practice on 11 July 2018. The overall rating for the practice was good, with safe rated as requires improvement. The full comprehensive report on the July 2018 inspection can be found by selecting the ‘all reports’ link for Brunel Medical Practice on our website at

www.cqc.org.uk

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This inspection was an announced focused inspection carried out on 9 October 2018 to confirm that the practice had carried out their plan to meet the legal requirement in relation to the breach in regulations that we identified in our previous inspection on 11 July 2018. This report covers our findings in relation to that requirement.

The overall rating for the practice remains unchanged as good. However, the safe domain is now rated as good.

Our key findings were as follows:

• The practice had taken measures since our previous inspection which ensured that systems and processes had been established for clinical oversight of the Quality Outcomes Framework (QOF) exception reporting rates especially in regard of matters of patient safety.
• Child safeguarding systems and process arrangements had been reviewed. New measures were in place which showed the required improvement had been made, including computerised alerts to assist clinical staff in supporting safeguarded patients.
• The practice had reviewed its systems and processes which ensured that medicines management was safely governed. For example, by checking staff understood that two forms of identity were required from the patient or their representative for the collection of controlled drugs.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating October 2015 – Good)

The key questions at this inspection 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 Brunel Medical Practice on 11 July 2018 as part of our inspection programme.

At this inspection we found:

• 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 a strong focus on continuous learning and improvement at all levels of the organisation. The practice embraced technological change to meet challenges. For example, on the new digital inclusion project which educated patients in using online services such as appointment booking, repeat prescriptions and patient summary records.
• Feedback to the practice management had been acted upon; such as carrying out a survey on the number of annual health checks on patients with learning disabilities (LD). The practice had acted on these findings and introduced signage which was dementia friendly, learning disability friendly and child friendly throughout the practice.
• A carer support worker was employed by the practice. This member of staff took referrals from clinical staff and contacted carers and carried out home visits to offer support. This included facilitating befriending services, bereavement support and referrals to other health professionals.
• The practice had a patient liaison lead who dealt with complaints, significant events, the patient participation group (PPG) and external links with voluntary organisations. The purpose of this new role was to develop and strengthen face to face relationships with patients and the community.
• The practice responded positively to the findings of our inspection and put in place new protocols to address any areas of concern during the inspection.

We found an area of outstanding practice;

• The practice had introduced an urgent on the day care team named the “Hot Team”. This comprised of a GP, two advanced nurse practitioners, a paramedic and a pharmacist with administration support. The Hot Team provided urgent care both at the practice and on home visits. This had a positive benefit to on average 90 patients a day who would otherwise have to attend alternative urgent care provider including the local hospital accident and emergency department or even not obtaining treatment at all until potentially too late. It also had a benefit to other patients as it freed up GP and nurse time to see routine appointments in a timely way.

The areas where the provider must make improvements are:

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

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.

Letter from the Chief Inspector of General Practice

Our previous inspection visit on 13 October 2015 found a breach of the following regulations;

• Regulation 12(2)(h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not ensure the actions taken following infection control audits were documented and that cleaning schedules were reviewed regularly and covered every area of the practice.
• Regulation 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have an effective audit system in place to ensure all medicines held at the practice were in date.

On 13 October 2015 we found the practice required improvement for infection control and for the proper and safe management of medicines and was rated as requires improvement for providing safe services. The practice was rated good overall and we rated all patient population groups as good.

This inspection on 10 May 2016 was undertaken to check the practice was meeting regulations. For this reason we have only rated the location for the key questions to which these relate. This report should be read in conjunction with the full inspection report published on 18 February 2016.

We found the practice had made improvements since our last inspection and was meeting the regulation that had previously been breached.

Specifically we found:

• The practice had introduced a new standard operating procedure which ensured that regular checks were made on all medicines at the practice including those in GPs bags and emergency kits.
• There were formal governance arrangements in place including systems for assessing and monitoring risks to the safe management of medicines.
• Prescription pads and prescription forms were stored securely at all times.
• All areas of the practice were clean and tidy. Cleaning schedules included all areas of the practice.
• A full infection control audit had been completed and identified actions had been carried out. Future regular infection control audits were planned for every six months.
• Staff had received training and understood how to use the new systems in place.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well-led services.

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 Brunel Medical Practice on 13th October 2015.

Overall the practice is rated as good. The practice is rated as good for providing effective, caring, responsive and well led services. However, we found that the practice requires improvements for providing safe services. Services for older people, people with long term conditions, families and young people, people whose circumstances may make them vulnerable and people experiencing poor mental health were rated as good.

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

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.

• Patients said they were treated with compassion, dignity and respect and were involved in decisions about their treatment. Information was provided to help patients understand the care available to them.

• Staff fulfilled their responsibilities to raise concerns and report incidents. All opportunities for learning from incidents were maximised.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).

• The practice was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.

• The practice had a business plan in place, monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We identified areas of outstanding practice;

The practice worked with their PPG and the local clinical commissioning group (CCG) to make improvements in response to patient needs. For example, the practice led a pilot scheme in the area which was a befriending service for parents/ guardians with pre-school children. This had a positive impact on families. Another pilot scheme was The Friendship Group which the practice ran and which organised social events such as cream teas. This had a positive impact on patients and continues to grow. Both of these were launched by the practice in response to meeting patient needs, in particular large numbers of patients in the older person population group and in the families’ population group. The practice had identified the issue of loneliness and social isolation in these two groups.

However there were areas where the provider must make improvements.

Importantly the provider must:

• Ensure that the findings, outcomes and actions taken following infection control audits are documented and that cleaning schedules are reviewed regularly and cover every area of the practice.

• Ensure that there is an effective audit system in place to ensure that all medicines held at the practice are not out of date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Brunel Medical Practice has its main site at Babbacombe and there are branches at St Marychurch and Shiphay.  The team of ten GPs provide medical care at all three sites supported by nurses and administrative staff from 7:30am until 6pm Monday to Friday. The phone lines open at 8am for emergencies and urgent care. The appointments line opens at 8:30am.

Out of Hours emergency cover is provided by another service.

During our visit we spoke with 15 patients  and three members of the patient participation group (PPG) who came in to meet us. We also spoke with six GPs, six nurses and four administrative staff including the practice manager. We also received information about the running of the practice prior to our visit.

At the time of this inspection the practice had not been successful in recruiting GPs following the retirement of two partners during 2013. The practice manager, patients and GPs who spoke with us were aware patients were not always able to get appointments when they wanted them. NHS England gave their approval for the closure of the practice list to new registrations from 1 August 2014 for 11 months and 28 days, apart from family members of current patients.

Brunel Medical Practice provided safe clinical care for patients. The practice was meeting the wide range of patients’ needs and it supported the continuity of patient care through established working relationships with other agencies and services. Staff knew how to safeguard vulnerable patients and children, and how to monitor and manage risk for patients.

The practice had a higher proportion of older patients registered than the national average. GPs had achieved the target of placing a named GP for each patient over the age of 75 years. Staff demonstrated competence in dealing with the health issues associated with older patients. GPs were focusing on reducing unplanned admissions to hospital.

Each GP led on a particular disease area as part of their Quality and Outcomes Framework (QOF) responsibilities, to maintain the quality of care provided for people with long term conditions. Specialist nurses provided weekly clinics for patients with chronic diseases.

Brunel Medical Practice had a higher proportion of patients under the age of 18 registered than the national average. The practice worked with community teams, health visitors and midwives to offer extra support to children, young people and families living in disadvantaged circumstances. Antenatal care was provided by midwives. GPs saw expectant mothers during their pregnancy at the request of the midwifery team.

For GP appointments the practice offered a mixture of pre-bookable appointments up to two weeks in advance as well as on the day appointments. Appointments with nurses could be booked up to four weeks in advance.  

Patients were referred to other services as required. If people were homeless, health needs were assessed and referrals to specialist support groups provided both opportunistically and as part of a long term plan of care. 

Patients diagnosed with a mental illness were recalled for routine check-ups annually. If they failed to attend three appointments or if they missed an appointment to receive medication for psychosis, the community mental health team was alerted. This was to reduce the risk of crisis through intervention and support.

Brunel Medical Practice was not meeting the requirements relating to staff recruitment. Full and relevant checks were not always completed for all staff prior to employment at the practice.

Areas that would benefit from improvement included standards and monitoring of environmental cleaning and completion of the fire risk assessment. There was not a system to ensure that training for administrative staff was kept up to date. There was not a method to record the learning points that had been identified when complaints were followed up.

Measures had been taken to improve the appointment system telephone access for patients. These needed to be kept under review because patients were still reporting difficulties with getting through.