This practice is rated as Good overall. (Previous rating January 2018 requires improvement) The practice was previously inspected on 23 January 2018 and was rated requires improvement for safe and caring, good for effective and responsive and inadequate for well-led

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Dr Durston & Partners on 12 September 2018 to follow up breaches of regulation identified at our previous inspection on 23 January 2018 and to check that action had been taken to comply with legal requirements. All of the previous reports are available by selecting the ‘all reports’ link on our website at www.cqc.org.uk.

At our last inspection the provider was rated as requires improvement for key questions: Are services Safe? Are services caring? And rated inadequate for key question Are services well led? We issued requirement notices in respect of breaches of regulation 12 of the Health and Social Care Act Regulations 2014. We issued a warning notice in respect of breaches of regulation 17 of the Health and Social Care Act Regulations 2014. The concerns related to lack of risk assessments associated with fire, legionella and infection control prevention. The provider did not have effective systems of governance to enable effective management of risks associated with fire, legionella, infection control, emergency procedures and recruitment.

In addition to the breaches of regulation we also made recommendations of other actions the practice should take.

At this inspection we found:

• Action had been taken on most of the issues identified at the previous inspection; those we required and those we recommended.

• Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions had been tightened, with stronger arrangements in place to keep people safe from abuse and address fire and other safety risks.

• Arrangements to respond effectively and act in the event of medical emergencies had improved and staff were suitably trained in emergency procedures.

• Systems for managing infection control had been improved. There was a suite of infection control policies in place. Risks associated with the control and spread of infections were adequately assessed in most areas. However risks associated with the control and spread of infections were not sufficiently mitigated in respect of carpets in the treatment and consultation rooms.

• Recruitment processes ensured that appropriate background checks had been completed or that risk assessments had been undertaken to consider their necessity. Staff had completed mandatory training. There was adequate indemnity insurance in place for all nursing staff.

• 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.

• We spoke with 2 GP partners, one practice nurse, an HCA and we reviewed 26 medical records. Clinical outcomes for patients were mostly in line with local and national averages and the practice had achieved improved outcomes against the targets set within the CCG for diabetes and childhood immunisations.

• Staff involved and treated patients with compassion, kindness, dignity and respect. Patient feedback on the day of the inspection was largely positive; results from the national GP patient survey July 2017 showed the practice had scored below the local and national average in respect of consultations with nurse. The practice was aware of these lower scores and had taken action in response to this.

• Arrangements were in place to ensure that actions from all meetings were followed up.

• More patients had been identified as carers, so that they could be offered information, advice and support.

However, we also found that although some concerns highlighted on our last inspection had been addressed there were some areas where sufficient improvement had not been made:

For example:

• The leadership had not planned for the impact of operating with fewer GP partners. This resulted in increased managerial responsibility on the remaining leadership.
• There was a lack of ongoing monitoring of the improvements in patient satisfaction with nursing staff.

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

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

Further details can be found in the requirement section at the end of the report.

The areas where the provider should make improvements are:

• Monitor the improvements made to ensure that they are consistently embedded. For example, continue to monitor infection prevention measures to keep patients safe.
• Continue to promote and monitor patient feedback.
• Continue to keep staffing levels under review to ensure staff welfare and safe care and treatment for patients.
• Review appropriateness of treatment rooms and activities carried on within them.
• Continue with work aimed at identifying patients with caring responsibilities to be able to provide appropriate support and signposting.

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 practice was previously inspected on 30 August 2016 and rated requires improvement for safe, effective and well led.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate

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 recently 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 Dr Durston & Partners on 23 January 2018 to follow up breaches of regulation identified at our previous inspection undertaken on 30 August 2016. At our last inspection the provider was rated as requires improvement for key questions: Are services safe? Are services effective? Are services well led? We issued requirement notices in respect of breaches of regulation 11, 12, 17 and 18 of the Health and Social Care Act Regulations 2014. The concerns related to lack of adequate knowledge around consent, lack of safe management of medicines, infection control concerns which had not been adequately mitigated. The systems around the management of significant events, safeguarding, recruitment and training and appraisal and the arrangements for responding to emergencies were either absent or ineffective.

In addition to the breaches of regulation we also made recommendations of other actions the practice should take.

At this inspection we found:

Although some concerns highlighted on our last inspection had been addressed there were some areas where sufficient improvement had not been made.

For example:

• The systems in place to manage risk were not effective and did not ensure patients remained safe. The arrangements in place to respond to emergencies were not sufficient as there was no fire policy and not all staff had received basic life support and fire training in accordance with current legislation and guidance. Recruitment processes did not ensure that appropriate background checks had been completed or that risk assessments had been undertaken to consider their necessity. There was not adequate indemnity insurance in place for two members of nursing staff. Risks associated with the control and spread of infections were not being adequately assessed in the case of legionella and not sufficiently mitigated in the respect of furnishings in the treatment room.

• Although we witnessed staff treating patients with compassion, kindness, dignity and respect and patient feedback on the day of the inspection was largely positive; the practice had scored below the local and national average in respect of consultations with nurses. The practice was unaware of these lower scores and had taken no action in response to this.

• We were told that staffing continued to be an issue and that the current operational model was unsustainable due to the demands on the service, the high turnover of patients and the comparatively high level of deprivation among their population.

However we also found that:

• Although the practice had not met targets related to immunisations; clinical outcomes for patients were mostly in line with local and national averages and the practice had achieved good outcomes against the targets set within the CCG. Clinical audit was used to improve the quality of care.

• Most patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• Practice staff were active within other local healthcare organisations which worked to improve the care provided to patients in the local area.

The areas where the provider must make improvements are:

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

• Ensure 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:

• Continue with work aimed at identifying patients with caring responsibilities to be able to provide appropriate support and signposting.

• Consider ways to formally record discussions around significant events, complaints and clinical updates.

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 R S Durston and Partners (Camberwell Green Surgery) on 30 August 2016. Overall the practice is rated as requires improvement.

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

• The practice did not have a policy for identifying and reporting significant events and some staff said that there were some significant events that had not been written up or reviewed due to time constraints.
• Some risks to patients were assessed and well managed although we found infection control risks that had not been identified and the practice’s recruitment procedures did not ensure that patients were protected from harm. Additionally we found that prescription pads were not secured and not all of the practice’s vaccine fridges had a failsafe thermometer. The practice’s emergency medicines were not stored in a way that made them immediately accessible to staff and we found that one of the oxygen masks had expired.
• Safeguarding processes and procedures were not sufficiently effective.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had received the clinical training to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Not all staff had been appraised within the last 12 months.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Some patients said they found it easy to make an appointment but others said that they would have to wait up to two weeks to get an appointment with their preferred GP. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Some staff were not aware of who acted as the lead in certain areas. Staff said that they could feedback concerns and suggestions to management but also felt that decisions affecting their work were often taken without prior consultation and that changes were not communicated effectively. The practice proactively sought feedback from patients, which it acted on.
• 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 that there is a robust governance framework supported by clear and appropriate policies and procedures.

• Put in place processes to regularly monitor infection risks from staff and the working environment and take action to effectively mitigate any identified risk.

• Put in place effective recruitment and monitoring procedures which comply with current guidance and legislation and ensure appropriate indemnity insurance is in place for all staff.

• Ensure all staff are appraised every 12 months.

• Ensure that steps are taken to maintain the security of prescriptions and safety of vaccines.

• Ensure that all relevant staff understand and follow their legal obligations around consent and capacity legislation.

• Ensure that systems are in place to monitor the expiry date of emergency equipment and that emergency medicines are easily accessible.

• Ensure that all staff complete mandatory training in accordance with current guidance and legislation.

The areas where the provider should make improvement are:

• Ensure that there are sufficient staff to provide a safe service.

• Review their processes around the registration and treatment of homeless patients.

• Ensure that all significant events are written up, reviewed and that action is taken where appropriate in a timely manner and put systems in place to record action taken in response to patient safety alerts.

• Review quality improvement work to ensure that audits and other quality improvement initiatives result in improved outcomes for patients.

• Ensure that care planning is undertaken for all patients where this is required, that there is effective information sharing with the local health visitor team and that palliative care meetings are documented.

• Improve the systems and process for involving staff in decision making and communicating change.

• Take action to improve patient awareness of translation, bereavement, carer support and mental health services in the waiting area and improve identification and the level of support offered to those with caring responsibilities or who have recently suffered bereavement.

• Continue to work on improving patient satisfaction with waiting times when they attend for an appointment.

We saw one area of outstanding practice:

• The practice had a Drug Misuse lead, who assisted in the running of a Substance Misuse Service for drug and alcohol users in conjunction with drug support workers. Over 80% of those patients who attend the clinic have remained on treatment for approximately nine years. The practice provided a letter from the current drug counsellor who stated that the conjoined working between the GPs in the practice and the counselling service had also improved the physical health of these patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice