Letter from the Chief Inspector of General Practice

This comprehensive inspection was undertaken on 31st August 2017 following a period of special measures, the practice is now rated as requires improvement.

We previously carried out an announced comprehensive inspection at Drs P Keating and H Appleton on 10 January 2017. Breaches of legal requirements were found in relation to services being safe and effective in the practice. We issued the practice with a requirement notice for regulation 17 good governance and warning notices for regulation 12 safe care and treatment and for regulation 18 staffing, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The warning notices required the practice to achieve compliance with the regulations by 28 April 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Drs P Keating and H Appleton on our website at www.cqc.org.uk.

We then conducted a focused inspection on 31 May 2017 to identify whether the practice had addressed the issues in the warning notices and now met the legal requirements. At the focused inspection on 31 May 2017 we found that the requirements of the warning notice had been met. The full report on the May 2017 inspection can be found by selecting the ‘all reports’ link for Drs P Keating and H Appleton on our website at www.cqc.org.uk.

This report relates to the follow up comprehensive inspection carried out on 31 August 2017

Our key findings were as follows:

• There was a policy for the management of high risk medicines however for one particular high risk medicine we found that one prescriber at the practice was unable to provide evidence through consultation notes that blood tests were reviewed prior to issuing a new dose of the high risk medicine. Some medicines are considered ‘high risk’ because the potential side effects mean appropriate blood monitoring and careful dose adjustment is required.

• There was a system in place for managing patient safey alerts however we identified that not all staff at the practice were clear on the process and the system had not yet been fully embedded.

• The practice had introduced a programme of clinical audits to drive improvement in patient care.

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

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

However, there were also areas of practice where the provider must make improvements.

• Ensure care and treatment is provided in a safe way to patients in relation to high risk medicines.

In addition the provider should:

• Review the process in place for managing patient safety alerts and ensure the system captures all alerts relevant to the practice.

• Review the programme of clinical audits to ensure it demonstrates lessons learned, evidence of improvement to patient care and/or identifies areas where improvement is required.

• Develop a strategy and supporting business plan that reflects the vision and the values of the practice.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

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 Drs P Keating and H Appleton on 10 January 2017. We found the practice inadequate for providing safe services and being effective. Breaches of legal requirements were found in relation to services being safe and effective in the practice. We issued the practice with warning notices for regulation 12 safe care and treatment and for regulation 18 staffing. The warning notices required the practice to achieve compliance with the regulations by 28 April 2017.

We undertook a focused inspection on 31 May 2017 to check that the practice had addressed the issues in the warning notices and now met the legal requirements. This report only covers our findings in relation to those requirements.

At the inspection, we found that the requirements of the warning notice had been met.

Our key findings across the areas we inspected for this focused inspection were as follows:

• We found that the practice implemented a system to monitor and investigate patient safety alerts; however when we checked three recent alerts only two had been documented in line with the new system.

• We found that the practice had put systems and process in place to keep patients safe from harm. For example, the practice had improved the system for safeguarding children and adults, checks to assess additional risks to the premises such as infection control and fire safety had been completed.

• There was a system in place for managing the learning needs and development of staff.

• There was evidence of a training programme to keep all staff up to date with mandatory training.

• We found that all staff had records of Disclosure and Barring Service (DBS) checks in their personnel files or evidence that the DBS check was underway as outlined in the practice recruitment policy.

The areas where the provider should make improvements are:

• Ensure all staff follow the practice protocol for acting on patient safety alerts.

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 Drs P Keating and H Appleton on 10 January 2017. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe services and being effective. Improvements were also required for providing caring and well-led services. It was good for providing a responsive service.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice had not assessed the risks associated with the absence of oxygen for use in medical emergencies; there were gaps in the system for safeguarding children and adults, the protocol for the handling of high risk medicines was incomplete, risk assessments to determine if staff who act as chaperones required DBS checks had not been completed; and checks to assess additional risks such as infection control, and fire safety and general health and safety were not completed.

• There was very limited or no monitoring of people’s outcomes of care and treatment, including no clinical audit. Data showed patient outcomes were notably low when compared to local and national averages, with significantly high exception reporting. Although we saw evidence of completed audits from 2014, we saw no evidence that audits were completed in the last two years.

• The system for managing the learning needs and development of staff through annual appraisal was inconsistent. There was no training programme in place to keep staff up to date and not all staff had completed mandatory training.

• The practice’s governance arrangements did not always support the delivery of high-quality person-centred care. For example, the practice had a number of policies and procedures to govern activity, however record keeping for governance meetings was limited and some policies had not been reviewed in several years.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity; national surveys identified that patient satisfaction was higher than the local and national average.

The areas where the provider must make improvements are:

• Assess the risks to the health and safety of service users of receiving the care or treatment in respect of the proper and safe management of medicines. Such as ensuring clear protocols are in place for managing the risks associated with high risks medicines.

• Ensure there is an effective programme for identifying the learning needs and development of staff, including a regular programme of staff appraisals and a programme of training is used to monitor training undertaken and training that is required.

• Assess monitor, manage and mitigate risks to the health and safety of service users. This includes effectively managing the risks associated with infection control and fire safety by ensuring annual infection control audits and fire risk assessments; implement a system for risk assessing the need for DBS checks for staff who act as chaperones.

• Ensure effective and sustainable clinical governance systems and processes are implemented to assess, monitor and improve the quality and safety of the services provided. Including; an effective system of managing patient safety alerts; a programme of audits to identify improvement to patient outcomes including completed clinical audits cycles; that clinical systems are used to identify and support vulnerable patients; to ensure there is an effective system for managing patients with long-term conditions and improving patient outcomes.

The areas where the provider should make improvement are:

• Improve governance arrangements within the practice. Including managing complaints and significant events, specifically around the process for reviewing individual complaints and events along with the dissemination of identified learning and outcomes; Implement a system for managing national guidance and implementing a system of formally recording clinical meetings and discussions.

• Improve the uptake in vaccinations for children under the age of two years.

• Implement a system to ensure patients with caring responsibilities are identified and recorded on the patient record system to ensure information, advice and support is made available to them.

• Implement an audit system in relation to the monitoring of prescription pads in accordance with national NHS guidelines.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice