Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dover House Surgery on 9 August 2016. The overall rating for the practice was good, however the effective domain was rated requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Dover House Surgery on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 16 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 9 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good overall including the effective domain.

Our key findings were as follows:

• There was a system in place for staff appraisals which included a comprehensive procedure; all staff were up to date with appraisals.

• There was a schedule of clinical audits which included two completed audits and a comprehensive clinical audit protocol policy.

• There was system in place to identify, record and provide support for carers. The number of carers recorded had increased to one percent of the patient population.

• The system for managing long term conditions and improving outcomes for patients suffering from mental health has been reviewed and significant increases in performance were achieved.

• Fire safety drills were carried out every six months, the most recent drill was completed in March 2017.

• Practice staff had been trained to use the defibrillator and there was an easy to read instruction guide available to all staff.

At our previous inspection on 9 August 2016, we rated the practice as requires improvement for providing effective services as there were no completed clinical audits, not all staff had been appraised and outcomes for patients with long-term conditions and mental health issues required improvement. At this inspection we found that the practice had a comprehensive system in place for clinical audits which included two completed audits within the last 12 months. We also found that the practice had updated and improved the appraisal system and all staff have been appraised within the last 12 months. We found that outcomes for patients with long-term conditions and those with mental health issues had improved. For example, patients with mental ill health who had a recorded care plan within the last 12 months had increased by 25% since our inspection in August 2016.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out this inspection to check whether improvements had been made since our last inspection of the service in February 2014. Following that visit we served warning notices for non-compliance with regulations in relation to care and welfare, safeguarding, infection control and quality assurance.

At that inspection we found that emergency procedures and equipment did not meet requirements and put patient safety and welfare at risk.

We also identified that the principle GP did not have the appropriate knowledge of safeguarding and policies for safeguarding adults and children were not up to date.

During that inspection we found that the updated infection control policy was not reflective of what the surgery undertook, there had been no recent infection control training. Cleaning did not meet required standards and no risk assessments had been undertaken and no action plan in place to make the appropriate improvements.

We looked at the arrangements for quality assurance and found a toolkit for managing incidents such as significant events had been put in place but none had reported or recorded. We found that risk assessments and audits of the environment or health and safety and infection control audits had not been carried out to ensure the premises were safe for patients.

At our inspection of the service on 30 April 2014 we found that improvements had been made in regard to care and welfare, safeguarding, infection control and quality assurance.

We found that emergency procedures had been developed and all emergency equipment now met UK Resuscitation Council guidance and appropriate equipment for health checks were being used and regularly tested.

The practice had improved its approach to safeguarding adults and children. Policies and procedures were now up to date and reflected best practice and the appropriate leads were in place who t had attended the required training.

Significant improvements to the management of infection control within the surgery had been undertaken with a complete refurbishment to all clinical and non clinical areas to ensure that any unnecessary risks were reduced. New cleaning arrangements were in place and regular checks were underway to ensure standards remained high.

Arrangements for quality assurance had improved. Patients were now participating regularly in the how the surgery was run. There were appropriate risk assessments in place and the surgery had improved its clinical review process to take account of significant events.

We looked at the personal care or treatment records of people who use the service, carried out a visit on 26 February 2014, talked with staff and reviewed information given to us by the provider.

At our last inspection in October 2013 we found that the provider was non-compliant with standards relating to care and welfare, safeguarding, infection control, medication, quality assurance and complaints. We found that emergency procedures and equipment did not meet requirements and put patient safety and welfare at risk. We identified that the principle GP had not undertaken level 3 child protection and adult safeguarding training and there were no up to date policies for safeguarding adults and children to protect patients from the risks of abuse. The infection control policy was not fit for purpose or up to date, No staff training and no risk assessments in relation to infection prevention and control.

The storage of medication in the surgery had improved since the last inspection. The provider has ensured that medication is stored correctly and has produced a prescribing policy to follow.

We looked at standards in relation to quality at the last inspection in October 2013. We found that the surgery was non- compliant with both quality assurance practices and complaints management. The provider was not identifying, assessing and managing risks related to the health, welfare and safety of patients. This included the analysis of incidents.

We found that complaints procedures were not in place at the last inspection. Since that inspection the provider has developed a complaints policy and ensured that patients are fully aware of how to make a complaint and who is responsible. The provider achieved compliance in regard to meeting this standard.

During this inspection we looked again at standards relating to care and welfare, safeguarding, infection control, medication, quality assurance and complaints.

We found that there were still no emergency procedures in place and equipment for supporting patients during an emergency did not meet the required standards. However, emergency medication was now up to date and stored appropriately.

We looked at safeguarding, we found that although some review of policies had been undertaken the procedures and protocols were not localised to the surgery. The provider (principle GP) had still not undertaken the required level of training for safeguarding adults and children and their continued to be a general lack of awareness across the staff group about this standard.

During this inspection we found that the updated infection control policy was not reflective of what the surgery does, there had been no infection control training. Cleaning did not meet required standards and no risk assessments had been undertaken and no action plan in place to make the appropriate

We looked again at quality assurance and found a toolkit for managing incidents such as significant events had been put in place but there had been none reported or recorded since our last visit. We found no risk assessments and audits of the environment or health and safety and infection control audits had not taken place to ensure the premises were safe for patients. Further action is being considered as a result of the continued breaches of the regulations.

During this visit we found that the provider was undertaking surgical procedures without registration. Due to the issues with infection control and premises risks the provider informed us and the NHS England body that they would not conduct these procedures until they had registered and sort to remedy the issues found by both bodies.

Patients’ needs were assessed and care and treatment planned and delivered in line with their individual plan of care. We saw four records, all included a summary of the consultation and details of proposed treatment including reviews. People were referred to an appropriate service if diagnostic tests were required, such as blood tests.

However, there were not sufficient arrangements in place to deal with foreseeable emergencies. There were no systems in place to ensure that the right emergency equipment was in place and that it was checked and fit for purpose.

We found no protocol for the recording of incidents or significant events. We asked the GPs whether they were aware of national patient safety guidance for significant events and they said they were but were not implementing it. This meant that the provider was not analysing and learning from incidents that could have resulted in harm to a patient.

The surgery was described by one patient as having “a good standard of cleanliness." Patients said they had seen clinical staff washing their hands before examining them or carrying out a procedure. However, there was no effective system in place designed to assess the risk of and prevent, detect and control the spread of health care associated infections.

Medicines were prescribed appropriately. A patient told us "the doctor checks my medication regularly" and "they advise me of when is best to take it." The arrangements for obtaining repeat prescriptions of medication were effective and patients were happy with this service.

Patients were not clear how they would go about making a complaint and were not aware of the surgery's complaints procedure. In addition there was no complaints policy or procedure in place.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dover House Surgery on 9 August 2016. The overall rating for the practice was good, however the effective domain was rated requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Dover House Surgery on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 16 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 9 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good overall including the effective domain.

Our key findings were as follows:

• There was a system in place for staff appraisals which included a comprehensive procedure; all staff were up to date with appraisals.

• There was a schedule of clinical audits which included two completed audits and a comprehensive clinical audit protocol policy.

• There was system in place to identify, record and provide support for carers. The number of carers recorded had increased to one percent of the patient population.

• The system for managing long term conditions and improving outcomes for patients suffering from mental health has been reviewed and significant increases in performance were achieved.

• Fire safety drills were carried out every six months, the most recent drill was completed in March 2017.

• Practice staff had been trained to use the defibrillator and there was an easy to read instruction guide available to all staff.

At our previous inspection on 9 August 2016, we rated the practice as requires improvement for providing effective services as there were no completed clinical audits, not all staff had been appraised and outcomes for patients with long-term conditions and mental health issues required improvement. At this inspection we found that the practice had a comprehensive system in place for clinical audits which included two completed audits within the last 12 months. We also found that the practice had updated and improved the appraisal system and all staff have been appraised within the last 12 months. We found that outcomes for patients with long-term conditions and those with mental health issues had improved. For example, patients with mental ill health who had a recorded care plan within the last 12 months had increased by 25% since our inspection in August 2016.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice