Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Laburnum Surgery in July 2015. The full comprehensive report on that inspection can be found by selecting the ‘all reports’ link for Laburnum Surgery, on our website at www.cqc.org.uk. At that inspection, the practice was rated as requires improvement. An announced follow up inspection was carried out in March 2016, and the practice was rated as good overall.

We carried out this focussed inspection on 26 September 2017, because the information we use to support our monitoring and decision-making indicated that the practice had higher rates of antibiotic prescribing, when compared to the local clinical commissioning group and England averages. Overall the practice is rated as good. Our key findings were as follows:

• The practice was taking steps to reduce their rates of antibiotic prescribing and had some systems and processes in place to help them do this. However, we found there were additional actions that staff should be taking, to strengthen the practice’s ‘antimicrobial stewardship’ arrangements. (‘Antimicrobial stewardship’ is an organisational approach to achieving the best clinical outcome for the treatment of a patient’s infection, whilst also having a minimal impact on resistance).

• At our previous inspection in March 2016, we asked the provider to arrange for the member of staff who was the practice’s infection control lead to complete more advanced infection control training. Whilst we were able to confirm at this inspection that all staff had completed training in infection control, the practice manager had been unable to source more advanced training for their infection control lead. Because it is important for infection control leads working in GP practices to have the knowledge and competencies required to take on this role, we are asking the provider to arrange for their infection control lead to undertake more advance training in infection control.

There were areas of practice where the provider needs to make improvements. The provider should:

Consider strengthening their ‘antimicrobial stewardship’ arrangements by:

• Arranging for all clinical staff to complete training in antibiotic prescribing.

  Adopting a recognised toolkit to help them assess and improve the effectiveness of their antibiotic prescribing.

• Making time in clinical and/or educational meetings for the whole clinical team to review their antibiotic prescribing practice and learn lessons to help drive improvements.

Arrange for the practice’s infection control lead to complete more in-depth training in infection control.

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 inspection of this practice on 16 July 2015. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

• Regulation 19 of the HSCA (Regulated activities) 2014 Fit and proper persons employed.

We undertook this focused inspection on 17 March 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Laburnum Surgery on our website at www.cqc.org.uk.

Our key findings were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Systems to manage and monitor the prevention and control of infection were in place.

• Disclosure and Barring Service checks (DBS) had been completed for all staff.

• Checks were made on NMC and GMC registration and that medical indemnity insurance was current.

• A fire drill had been carried out in the last year.

• Each member of staff had their own individual training record which set out what training they had received and when, therefore making it easy to see when refresher training was due.

• The most current published data from 2014/15 showed an improvement in the childhood immunisation rates and that they were now mostly in line with CCG/national averages.

• The practice had a system in place for handling complaints and concerns. Complaints received had been fully investigated and responded to by the practice.

• The were governance arrangements in place.

  However, there was one area of practice where the provider needs to make improvements.

  The provider should:

• Provide specific infection control training for the infection control lead at the practice.

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 Laburnum Surgery on 16 July 2015. Specifically, we found the practice to require improvement for providing safe and responsive services and for being well led. They were rated as good for providing effective and caring services.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was a system in place for reporting, recording and monitoring significant events.

• Some risks to patients and staff were not assessed and systems and processes were not fully implemented to keep patients safe. For example, the practice did not follow its recruitment policy. Some staff had not undergone recruitment checks.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. We saw a system of clinical audit to improve outcomes for patients. However, child immunisation rates were significantly lower than the clinical commissioning group (CCG) averages for some groups.
• Staff had received training appropriate to their roles. There was an appraisal system in place.

• Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Data showed that patients rated the practice lower or in line with the CCG averages for being caring.

• Most patients we spoke with and those who completed CQC comment cards indicated they felt they could obtain appointments, including urgent appointments, when needed.
• The practice had a system in place for handling complaints and concerns; however this was not fully developed.

• The practice proactively sought feedback from patients and conducted an annual patient satisfaction survey.

• There was a vision and a strategy for the future and a leadership structure and staff felt supported by management. However, some of the systems and processes which should have been in place to keep patients and staff safe were not in place.

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

Importantly, the provider must:

• Ensure recruitment procedures are established and that they operate effectively.

In addition the provider should:

• Improve the way staff training is recorded.
• Carry out infection control training for staff.
• Improve the way complaints are investigated and responded to.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

People expressed their views and were involved in making decisions about their care and treatment. We saw staff dealt with enquiries from patients as discretely as possible. Patients told us they were happy with the treatment they received. One patient told us, “The reception staff and doctors are really friendly. They are good at explaining things.”

We spoke with three patients who were all complimentary about the care they received. One patient told us, “They make you feel welcome and ask you what problems you have.” Another patient said the doctor had given her the correct advice about taking her child to hospital, where they had received prompt and appropriate treatment.

The practice had in place safeguarding policies for both children and vulnerable adults. There was an identified lead clinician with clear roles and responsibilities to oversee safeguarding within the practice.

The practice was well organised and presented as clean, tidy and well maintained. There was easy access for people with a disability, as most services were located on the ground floor. The practice undertook a fire risk assessment and confirmed they carried out and logged weekly fire tests.

Staff told us that they felt well supported in their work. One staff member told us, “I have never worked anywhere where the GPs treat you so much as an equal. It is all very friendly.” We saw copies of attendance sheets for various training including safeguarding and updates on information systems.

This practice is rated as requires improvement overall. (Previous rating June 2018 – inadequate.)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Laburnum Surgery, on 18 and 22 February 2019. At this inspection we followed up three breaches of regulations identified during our previous inspection, in June 2018.

We based our judgement of the quality of care at this service 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 and other organisations.

We have rated this practice as requires improvement overall.

We have rated the practice as requires improvement for providing safe and well led services because:

Although most of the shortfalls we identified at our last inspection had been fully addressed, we found there were still areas where the provider needed to improve, to demonstrate they could sustain improvements over time. In particular:

• Leaders were not fully engaged in local safeguarding processes.

• Leaders could not demonstrate staff were up-to-date with their routine immunisations.

• There were some shortfalls in the practice’s systems for the appropriate and safe use of medicines.

• The practice’s rate of antibiotic prescribing continued to be significantly higher than the local clinical commissioning group (CCG) and national averages.

• Checking that the practice’s vaccine refrigerators were maintained in a clean condition, and that checks of the vaccine refrigeration temperatures were accurate and carried out consistently.

• The practice needs to continue to improve how they engage with patients.

• The practice needs to demonstrate that they can sustain improvements to their governance arrangements over time

We have rated the practice as inadequate for providing effective services because:

Although most of the concerns we identified at our last inspection had been fully addressed, we found there were still areas where the provider needed to improve, to demonstrate they could sustain improvements over time.

• The practice could not demonstrate they had a comprehensive planned programme of quality improvement.

• Outcomes for people who use services were below expectations, when compared to similar services, and this affected all population groups.

The lack of a systematic programme of clinical and internal audit impacted on all of the population groups. Also, the outcomes for working age patients and patients who experience poor mental health were below expectations, when compared to similar services and because of this, we have rated these two population groups as inadequate.

We rated the practice as good for providing caring services because:

• Staff treated patients with kindness and respect, and involved them in decisions about their care.

We rated the practice as good for providing responsive services because:

• The practice organised and delivered services to meet their patients’ needs.

• Patients could access care and treatment in a timely way.

The overall rating for this practice was requires improvement due to concerns in providing safe, effective and well-led services. However, the population groups were rated as good for providing responsive services because patients could access timely and responsive care and treatment.

We found that:

• The provider had complied with the requirement notices we issued relating to: establishing and operating appropriate staff recruitment procedures; providing staff with appropriate support and appraisal, to enable them to carry out their duties. The provider had also complied with most aspects of the requirement notice relating to good governance.

• The practice had improved their systems and processes for keeping patients safe and safeguarded from abuse.

• The practice learnt and made changes when things went wrong.

• The practice had improved their arrangements for monitoring and reviewing activities, enabling them to have a better understanding of risks.

• The practice’s systems and processes for ensuring the safe management of medicines had improved since our last inspection. This included improvements in the arrangements for antimicrobial stewardship. However, there were still some shortfalls in the practice’s arrangements for ensuring the appropriate and safe use of medicines.

• The practice’s arrangements for reviewing the effectiveness of the care staff provided to patients had improved since our last inspection. However, the practice did not have a planned systematic programme of clinical and internal audit, to help monitor and improve standards of care.

• The practice could demonstrate an improved Quality and Outcomes Framework (QOF) performance for 2018/19. However, outcomes for some of the population groups were still below expectations when compared to similar services.

• Overall, the practice could demonstrate that staff had the skills, knowledge and experience to carry out their roles.

• Overall, patients could access care and treatment in a timely way.

• Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.

• The practice had improved and strengthened their governance and management arrangements. However, there were still shortfalls in these arrangements.

• The practice had developed a credible strategy to help them provide high-quality, sustainable care, and address the key challenges they faced.

• The practice had systems and processes for learning and continuous improvement.

The areas where the provider must make improvements are:

• 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:

• Record the outcome of their assessment of the ongoing prescribing competence of the nurse practitioner working at an advanced level.

• Improve how patients who are also carers are identified.

• Improve their arrangements for engaging with patients.

• Improve systems and processes for monitoring the practice’s QOF performance and reduce those exception reporting rates that are higher than the local clinical commissioning group and national averages.

• Improve uptake rates for cervical, breast and bowel screening to bring them in line with the local CCG averages and national screening programme targets.

• Develop a succession plan, to help assure the future delivery of services.

• Engage with the local safeguarding network.

• Prepare a comprehensive schedule of quality improvement activities, to help drive targeted improvements at the practice.

This service was placed in special measures in September 2018. Insufficient improvements have been made such that there remains a rating of inadequate for providing effective services. Therefore, we are taking 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. Where necessary, another inspection will be conducted within 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.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice