This practice is rated as Requires Improvement overall. (Previous rating 12 2017 – Requires Improvement)

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? - Inadequate

We carried out an announced inspection at Cranbrook Surgery on 5 December 2018. This inspection was undertaken in line with our inspection programme of re-inspecting practices where a breach or breaches of regulations was identified at our previous inspection.

At our previous inspection in December 2017, we issued the practice with requirement notices in respect of regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Act (Regulated Activities) Regulations 2014, as the practice had not addressed all concerns identified at a previous inspection held in August 2016.

At this inspection we found:

• 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.
• Not all the practice systems to manage the day-to-day governance at the practice functioned well. We noted that there was no system in place to ensure blank prescriptions pad were logged when delivered to the practice.
• Some patients found they could not always gain appointments which suited their needs.
• Patient Group Directions (PGD’s) used by the practice nurses to allow them to administer medicines, were not kept in an organised manner, making it difficult to identify patients who should be in receipt of medicines.
• The practice and PPG worked together to ensure that quality care was delivered and could be accessed easily at the practice.
• Staff appraisals had not been completed during the last 12 months for the majority of administrative staff.
• Some actions on the latest NHS England infection and prevention control audit had not been actioned, despite a timescale for completion being agreed.
• The practice premises are in need of refurbishment and one of the clinical rooms was not compliant with the criteria identified in the national infection and prevention control standards.

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

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

The areas where the provider should make improvements are:

• Monitor systems and process to address continuing patient concerns in relation to access to care at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall.

The last inspection of this practice took place in August 2016. At that time the overall rating for the practice was requires improvement, with the key question of safe rated as inadequate and the key question of effective rated as good. All other key questions were rated as requires improvement. Our concerns at that time centred around lack of good governance as the practice had weakness regarding lack of robust policies and procedures for safeguarding patients from possible abuse and not ensuring that the practice provided safe care and treatment at all times. At this time, we issued the practice with requirement notices in respect of regulation 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we rated the practice as follows for the key questions :-

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement

We carried out an announced comprehensive inspection at Cranbrook Surgery on 5 December 2017. This inspection was conducted as follow-up full comprehensive inspection to ensure that the practice had put into action the changes they had informed the Commission they would implement following the last inspection in August 2016.

At this inspection we found:

• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
• There was no regular oversight by the GP partners of the nursing provision provided at the practice.
• Staff encouraged and supported patients to be involved in monitoring and managing their health.
• Some patients found it difficult to obtain appointments when they required one.
• The National GP Patient Survey showed that patient satisfaction scores with the practice was below the national average.
• The practice learned lessons from individual concerns and complaints, and used this information to improve services at the practice.
• There was no evidence of a failsafe system for checking and monitoring cervical screening results.
• We saw evidence that clinical audits had a positive impact on quality of care and outcomes for patients.
• The practice premises are in need of refurbishment and one of the clinical rooms is not compliant with national infection control compliant standards.

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

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

• Establish effective systems and processes to address continuing patient concerns highlighted in the National GP Patient Survey scores.
• Ensure that job descriptions are devised for all members of staff.
• Establish an effective system to record actions following receipt of safety alerts.
• Look at ways to conduct effective pre-travel assessments for patients requiring vaccines.
• Continue progress on recording complaints in an effective and detailed manner.

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 Cranbrook Surgery on 19 August 2016. Overall, the practice is rated as requires improvement.

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

• There was a system for recording and reporting significant events however, there was no system in place to monitor that lessons learnt were shared with all staff and there were no monitoring systems in place to ensure action was taken to improve safety in the practice.

• Patients were at risk of harm because systems and processes did not ensure their safety. Policies were out of date and the provider had failed to monitor and mitigate risks identified in infection control audits.

• We found concerns in relation to medicines management. There was no system in place to follow-up patients who failed to collect their prescriptions and we found an example of a patient being prescribed a high-risk medicine outside of recommended guidelines.

• The practice had only identified 0.3% of their practice population as carers.

• Information about services was available but not everybody would be able to access it.

• Feedback from patients reported that access to a named GP was not always available quickly, although urgent appointments were usually available the same day.

• The practice was equipped to treat patients and meet their needs.

• There was a lack of managerial oversight and risks to patients, staff and the running of the practice were not always assessed and mitigated against. Governance arrangements did not ensure the practice was run safely and effectively, and performance was not being monitored in all areas.

• The practice did not have an effective system for managing complaints. The practice had adequate arrangements in place to respond to emergencies and major incidents.

• There was a clear leadership structure and staff felt supported by management.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way for patients. This includes introducing effective processes for significant events, medicines prescribing and infection prevention and control.

• Ensure procedures and policies protect people from the risk of abuse.

• Ensure effective systems are in place for receiving and recording complaints.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

In addition, the provider should:

• Review and respond to the GP national survey regarding patient satisfaction scores for nurse consultations.

• Advertise within the practice the provision of services including online services and translation services for patients and consider improving the layout for leaflets and notices displayed in the practice to make them accessible to patients.

• Review the information displayed on the practice website and monitor this regularly so patients are up to date with information.

• Proactively identify and support patients who are carers.

• Consider improving communication with patients who have a hearing impairment.

  Consider improving facilities for parents such as baby changing facilities.

• Review the appointment system to ensure patients have timely access to appointments.

• Ensure patients can have access to a GP of the same gender as them if they wish.

• Review ways to increase take up of cervical screening, to improve patient outcomes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice