Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A T Fernandes and Partners on 2 August 2016. The overall rating for the practice was Good; however the practice was rates as Requires Improvement for the key question ‘are services well led’. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr A T Fernandes and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 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 2 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as Good. Specifically, following the focused inspection we found the practice to be good for providing well led services.

At our previous inspection on 2 August 2016, we rated the practice as requires improvement for providing well led services as the provider had not established governance systems and processes to enable the practice to operate effectively, including addressing action plans– such as those arising from risk assessments; introducing systems to monitor compliance with NICE and other guidance; ensure risk assessments are up to date, and carry out regular fire drills.

We also highlighted other areas where the provider should take action:

• Take appropriate steps to identify patients who are also carers to allow the practice to provide support and suitable signposting.

• Regularly review complaints received so as to establish if there are any trends developing and if so, take appropriate action.

• Complete audit cycles by re-auditing.

• Enable staff to undergo adult safeguarding training.

• Revise the infection control audit template so that it covers all areas of potential infection risk; and review the needlestick injury guidance so that the infection prevention control policy and guidance posters give the same advice.

• Carry out annual reviews on vulnerable patients, including those with a learning disability, dementia and mental illness.

• Keep records to indicate when clinical equipment is cleaned.

• Review the outcomes of the national patient survey and consider ways to improve patient experiences.

• Ensure all GPs have appropriate medical indemnity insurance in place.

Our key findings at this focused inspection were as follows:

We found that the provider had taken action to address the breaches of regulation identified at our previous inspection.

The provider had introduced new governance systems, and updated existing ones. Changes included holding weekly operational meetings, with a practice wide senior management team meeting every fourth week.

A system to monitor NICE and other guidance had been instigated, and included assessing how well the practice was complying with the guidance.

Risk assessments had been updated and were regularly reviewed. Fire drills had been carried out.

We also found that the provider had taken the following action to address the areas where we suggested they should make improvements:

• The practice had taken steps to improve its identification of patients who were also carers. Information had been added to the practice website and practice leaflet. A poster had been placed in the waiting area, and staff used ad-hoc opportunities, such as during the flu jab campaign, to contact carers. The number of identified carers had risen from 48 at the last inspection to 71 (0.5% of the patient list) at the time of this inspection.

• Reviews of complaints had been carried out and shared with the patient participation group. The practice found that most complaints related to the telephone system and appointment booking process, both of which they were taking steps to address. Technical issues had been found with the phone system which the telephone provider was working to address. The practice acknowledged that there were sometimes difficulties with appointments, not least because of a shortage of GPs. They were trying to work around this by, for example, appointing a pharmacist, and setting up a local community development programme. This programme aimed at reducing patient dependency and encouraged patients to consider alternatives to visiting their GP. The programme included setting up hubs to provide, for example, fitness classes; education and vocational training, food banks; finance and housing advice and tea and coffee clubs. To date, the practice had secured funding to set up three classes, in the community, for older people – including a health and fitness group and a health session.

• Senior staff were now logging when initial audits were carried out, and setting diary notes to ensure audits cycles were completed with a second cycle. Details of audits to be completed were also added to the practice’s action plan so that they were regularly reviewed. The practice had carried out a complete audit with regard to NICE guidance recommending all new patients should be offered an HIV test.

• We were provided with a spreadsheet outlining staff training. It indicated that all permanent staff had undergone adult and children safeguarding training to the appropriate level, with one exception amongst the administrative team. This person had training booked to take place within the next few days.

• The practice’s infection control audit template had been revised and now covered all areas of potential infection risk. The needlestick injury policy had been updated and both the policy and posters highlighting the action to be taken in the event of a needlestick injury both now gave the same information.

• The practice told us they were prioritising annual care plan reviews for vulnerable groups. At the end of the last (financial) year, 81% of patients with a mental health illness; 75% of patients with dementia and 47% of patients with a learning disability had received a review. The practice acknowledged that they had still not achieved their 100% target; however these figures were an improvement since the last inspection.

• Staff were keeping a record to show when clinical equipment was being cleaned.

• We were told staff had used protected learning time to sit down as a group to review the results of the national patient survey and identify areas for improvement. Key issues in the survey corresponded to complaints received, and were areas where the practice was already trying to improve, such as telephone access and appointments.

• Details of all the GPs’ medical indemnity insurance was now being kept centrally on the training spreadsheet and renewal dates were being diarised. The practice told us all GPs’ indemnity was in place and up to date. We saw this was the case in the staff file we reviewed.

However, there remained areas of practice where the provider should make improvements.

Importantly, the provider should:

• Continue to prioritise annual care plan reviews for vulnerable groups, particularly those with a learning disability.

• Continue to take appropriate steps to improve identification of patients who are also carers so as to be able to provide appropriate support and signposting to this patient group.

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 Dr AT Fernandes on 2 August 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and in most cases well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Data from the Quality and Outcomes Framework (QOF) showed most patient outcomes were comparable to the national average.

• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

• Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. However we found learning from complaints had not been entrenched as issues were repeated.

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

• The practice had a vision and a strategy and staff knew and understood the practice values.

• The provider was aware of and complied with the requirements of the duty of candour.
• The practice had a governance framework to support the delivery of the strategy and good quality care however we found some systemic weaknesses in governance systems which impacted on the services being provided.

The areas where the provider must make improvement are:

• Establish governance systems and processes to enable the practice to operate effectively, including addressing action plans; introducing systems to monitor compliance with NICE and other guidance; ensure risk assessments are up to date, and carry out regular fire drills.

The areas where the provider should make improvement are:

• Take appropriate steps to identify patients who are also carers to allow the practice to provide support and suitable signposting.

• Regularly review complaints received so as to establish if there are any trends developing and if so, take appropriate action.

• Complete audit cycles by re-auditing.

• Enable staff to undergo adult safeguarding training.

• Revise the infection control audit template so that it covers all areas of potential infection risk; and review the needlestick injury guidance so that the infection prevention control policy and guidance posters give the same advice.

• Carry out annual reviews on vulnerable patients, including those with a learning disability, dementia and mental illness.

• Keep records to indicate when clinical equipment is cleaned.

• Review the outcomes of the national patient survey and consider ways to improve patient experiences.

• Ensure all GPs have appropriate medical indemnity insurance in place.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice