This practice is rated as Requires improvement overall. (Previous inspection 1 May 2018 –Where there was not sufficient evidence to rate.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Requires improvement

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 Essex Lodge on 28 August 2018 as part of our inspection programme to follow up on breaches of regulations identified during an unannounced focused inspection carried out on 1 May 2018, in response to concerns that were reported to us, and to check whether the practice had carried out their plan to address requirements relating to breaches of regulations identified a prior inspection on 24 April 2017.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Systems for receiving and dealing with complaints and whistleblowing were ineffective.
• Leadership and governance arrangements were generally effective, except for some aspects of HR
• There was a need to continue to improve and embed leadership and team cohesion.

The areas of practice where the provider must make improvements are:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Establish 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:

• Review and improve rates for females, aged 50-70, screened for breast cancer in last 36 months.
• Review and improve systems to ensure clear and appropriate arrangements for emergency medicines and Patient Specific Directions (PSDs).
• Continue to improve and embed a cohesive working culture at all levels of staff.
• Continue to embed and ensure NHS contracted resources such as appointments are not used for private patient’s appointments.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We first carried out an announced inspection of Essex Lodge on 29 February 2016 and the practice was rated as requires improvement for providing safe and effective services, good for caring and responsive services and requires improvement overall. We then carried out a follow up focused inspection on 24 April 2017 to consider whether sufficient improvements had been made for provider to meet legal requirements and associated regulations. The practice was rated as good for providing safe services, requires improvement for effective services due to a breach of regulations, and good overall.

This inspection was an unannounced focused inspection carried out on 1 May 2018 in response to concerns that were reported to us, and to check whether the practice had carried out their plan to address requirements relating to the breach in regulations we identified in the previous inspection on 24 April 2017.

Our key findings were as follows:

• Significant events were not consistently identified or acted upon to improve patient safety.
• A GP partner was using NHS practice resources including NHS appointments, staffing, premises and equipment for a private patients cosmetic and slimming clinic business.
• Do not attempt resuscitation arrangements (DNAR) for patients in a nursing and care home were not provided with their consent or consent of the relevant person.
• There was an unsatisfactory working culture including staff withholding, changing or being worried about providing us with information and there were divides between staff teams at all levels, including the leadership team.

Whilst previous concerns had been remedied, new issues of concern were identified at this inspection.

There were areas of practice where the provider must make improvements:

• Ensure that care and treatment of patients is only provided with the consent of the relevant person.
• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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 Essex Lodge on 29 February 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Essex Lodge on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 April 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 29 February 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. At the previous inspection we rated the practice as requires improvement for safety and effectiveness as some of the arrangements in respect of cleanliness and infection control were not adequate. There were also concerns around medicines management and the practice’s arrangements to deal with emergencies. We also found there was no formal induction process in place and patient consent for minor surgery or IUCD (“coils”) procedures was not being consistently sought and/or recorded. As a result the practice was rated as requires improvement overall.

At this inspection we found improvements had been made in those areas and the practice is now rated good for safety. However we found that a significant number of staff were one or two months overdue for some mandatory training. At the time of the inspection the practice did not have a clear picture about its position with regards to staff training. Following the inspection we received records demonstrating the stated irregularities. Consequently, whilst improvements had been made, a new issue of concern was identified at this inspection. As a result the practice is still rated as requires improvement for being effective.

Our key findings were as follows:

• Adequate arrangements were in place in respect of infection control audits and cleaning schedules. However some staff were overdue for infection control training.

• Risks to patients were assessed and well managed.

• Patient specific directions (PSDs) were in place to ensure Health Care Assistants (HCAs) were safely administering vaccines in line with legislation.

• A protocol was in place for action in the event of the medicines refrigerator going out of range.

• Records showed not all staff training was complete and up to date.

• Adequate arrangements were in place for the seeking and recording of patient consent for invasive procedures.

In addition, at our previous inspection we said the practice should:

• Ensure implementation of plans for embedding induction and Disclosure and Barring Service (DBS) checks for non-clinical staff or an appropriate risk assessment.

• Review systems for complaints, communication arrangements for patients who are deaf or hard of hearing, and improve identification of carers.

At this inspection we found:

• A comprehensive induction programme was now in place and DBS checks had been carried out for all staff.

• Recording and tracking processes for complaints had improved and we saw evidence of discussion and regular analysis of complaints. Patients who were known to have a hearing impairment were flagged on the system with instructions on how best to communicate with that patient. There was no hearing loop in place but this was planned for as part of the ongoing redevelopment of the practice premises.

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

Importantly, the provider must:

• Ensure all staff receive such appropriate training as is necessary to enable them to carry out the duties they are employed to perform.

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 the Essex Lodge practice on 29 February 2016. Overall the practice is rated as requires improvement.

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.
• Some risks to patients were assessed and well managed such as fire safety but others were not such as infection control, medicines management and arrangements in the event a medical emergency.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance and generally had the skills, knowledge and experience to deliver effective care and treatment.
• Patients’ consent had not consistently been sought and recorded.
• 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.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had facilities and was equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management and the practice 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.

The areas where the provider must make improvements are:

• Ensure safe and effective arrangements for infection prevention and control, flooring in clinical rooms, medicines management and equipment in case of a medical emergency.
• Ensure a system for production of Patient Specific Directions (PSDs) to enable healthcare assistants to administer specific injectable medicines with a GP or nurse on the premises.
• Implement effective arrangements for seeking and recording patients’ consent.

The areas where the provider should make improvements are:

• Ensure implementation of plans for embedding induction and DBS checks for non-clinical staff or an appropriate risk assessment.
• Review systems for complaints, communication arrangements for patients who are deaf or hard of hearing, and improve identification of carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice