Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elm Tree Surgery on 25 May 2016. Overall the practice is rated as good. This inspection was a follow-up of our previous comprehensive inspection which took place in Ocotber 2015 when we rated the practice as inadequate overall. In particular the practice was rated as inadequate for providing safe and well-led services and was placed into special measures for a period of six months.

After the inspection in October 2015 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

The inspection carried out on 25 May 2016 reflected that the practice had made significant improvements to enable the practice to come out of special measures and achieve a rating of good overall. They had responded to the concerns raised and had complied with the requirement notices that we issued and the enforcement action taken.

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

• There was an open and transparent approach to safety and an improving system in place for reporting and recording significant events.
• Risks to patients were assessed and 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.
• 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.
• Patients 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.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice:

Patients were able to access appointments and services in a way that suited them. The practice offered prompt access to appointments with the GP of patient choice. Feedback on access to services was consistently better that the locality and national averages and a range of services were offered that recognised the needs of the practice population.

The practice offered an extended minor injuries service to enable patients to access this locally and avoid a trip to the hospital Accident and Emergency (A&E). The last data available showed the practice had 180 patients attend A&E in one year compared to the local average of 235 and national average of 388.

The practice had researched childhood immunisation regimes in other countries. This resulted in aligning immunisations with overseas practise and resulted in a high rate of take up of childhood immunisations among the families of patients from other countries.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this 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 of Elm Tree Surgery on 20 October 2015.

This was the first inspection using the CQC comprehensive inspection programme. Overall the practice is rated as inadequate. Elm Tree Surgery was committed to delivery of caring and responsive services for its patients. However, the practice did not demonstrate a culture of managing safety and assessing and managing risk.

We found the practice good for the delivery of effective and caring services and outstanding for provision of responsive services. However, the practice was found to be inadequate for provision of safe and well led services and these ratings affected all the population groups.

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

• The practice performance in achieving high rates of cervical cytology screening and childhood immunisations was as good as, or better than, other practices in the locality. This was achieved within the context of a high turnover of female patients, a birth rate double the national average and the need to harmonise immunisation regimes with those of other countries.

• Patients were able to access same day appointments and routine appointments were available within two days. Patient feedback showed they could see the GP of their choice promptly to maintain continuity of care.
• The practice recognised the needs of the rural population. For example dispensed medicines could be collected from two local post offices and flu clinics were held in village halls.
• Although there was evidence of effective clinical leadership that were engaged in leading and ensuring the delivery of care we also found that this was not supported by the necessary management infrastructure and leadership.
• 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.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Data showed patient outcomes were above average for the locality and above national averages.

However,

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, learning from such events was communicated inconsistently.
• Staff were able to recognise signs of abuse but were unclear of their responsibilities to report suspected abuse to statutory authorities.
• Procedures to keep medicines safe were not operated effectively.
• Governance arrangements in the practice were weak and improvements were required in relation to the management and assessment of risk. For example, Actions to reduce the risk of cross infection had been identified via audit but had not been taken in a timely manner. The practice did not demonstrate a culture of managing safety and assessing risk.
• Staff of the practice reported that management did not routinely seek and act on staff feedback.
• We identified poor levels of collaboration and cooperation between specific team members and some staff reported a level of conflict with inappropriate behaviour directed towards them.

• Staff were appropriately trained to carry out their duties but had not been involved in identifying their training needs.

We saw areas of outstanding practice:

• Patients were able to access appointments and services in a way that suited them. The practice offered prompt access to appointments with the GP of patient choice. Feedback on access to services was consistently better that the locality and national averages and a range of services were offered that recognised the needs of the practice population.

• The practice offered an extended minor injuries service to enable patients to access this locally and avoid a trip to the hospital A&E. The last data available showed the practice had 180 patients attend A&E in one year compared to the local average of 235 and national average of 388

• The practice had researched childhood immunisation regimes in other countries. This resulted in aligning immunisations with overseas practice and resulted in a high rate of take up of childhood immunisations among the families of patients from other countries.

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

Importantly, the provider must:

• Improve the management of medicines to ensure they are held safely and update processes used to reduce the risks associated with medicines.
• Ensure patient records are maintained safely with staff having secure personal access to the records system.
• Introduce an appropriate system that is accessible to all staff to record and report back on significant events.
• Ensure all relevant risk assessments are undertaken and any action arising from such assessments is undertaken.
• Ensure staff training in safeguarding includes reporting a concern to the relevant authorities. Update the local safeguarding contact details within the practices safeguarding protocols.
• Ensure appraisals take place on a regular basis and that staff receive support and supervision relevant to their roles.
• Ensure risks identified from the 2014 control of infection audit are addressed and undertake annual control of infection audits.
• Develop and implement cleaning schedules for all areas of the practice.

In addition the provider should:

• Promote the availability of the chaperone service.
• Ensure all staff are aware of the translation service and how to access this for patients.

I am placing this practice in special measures. Practices 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 practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elm Tree Surgery on 26 February 2019, as part of our inspection programme. The service was previously inspected on 23 June 2016, and rated Good overall.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

This means that:

• Patients had good outcomes because they received effective care and treatment that met their needs.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met by the way in which services were organised and delivered.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• Patients could access appointments and services in a way and at a time that suited them. Routine appointments were available within two working days, urgent appointments were offered on the same day and extended hours surgeries ran on three evenings every week.
• The practice was significantly (around 21 percentage points) above local and national averages for patient satisfaction, across a range of indicators. For example, access to services, and satisfaction with the type of appointment offered.
• The practice is involved with and supports a number of initiatives to improve diabetic health outcomes. For example:

  • A local support group for diabetic patients was developed by a practice nurse. The group is now led by diabetic patients and their families. Meetings are attended by around 20 people, and the group meets six times per year. Guest speakers have addressed cholesterol checks, glucose monitoring, and other relevant subjects.
  • A practice nurse set up and ran a diabetic education discussion group and developed a diabetes care handbook. The handbook has been adopted by the local clinical commissioning group, for use by other practices in the Swindon area.

We found areas where the provider should make improvements. The provider should:

• Continue to identify carers to enable this group of patients to access the care and support they require.
• Continue efforts to improve rates for childhood immunisations.
• Continue efforts to increase the programme coverage of women eligible to be screened for cervical cancer.
• Review arrangements for medicines storage and security, in areas accessed by contract staff. The practice building was secure and prescriptions could be easily tracked. However, the practice's assurance processes did not include its own checks for contract staff accessing the premises.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice