Letter from the Chief Inspector of General Practice

We first carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. The ratings for this inspection were:

Safe – Inadequate

Effective – Inadequate

Caring – Good

Responsive – Requires improvement

Well led – Inadequate

The overall rating for the practice was inadequate and the practice was placed in special measures. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Leesbrook Surgery on our website at www.cqc.org.uk.

Following the inspection on 15 March 2016 two warning notices were issued to Leesbrook Surgery in respect of the need for consent and fit and proper persons employed. We carried out a follow up inspection on 20 September 2016 and found the practice had met the requirements of the warning notices.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 12 January 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Most risks to patients were assessed and well managed.
• Some fire safety risks and clinical waste risks had not been assessed.
• 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.
• Patients said they usually found it easy to make an appointment with a 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.
• The practice employed a community matron who predominantly worked with older patients. They monitored hospital admissions so patients received appropriate support to avoid further admissions when they were discharged. They also worked closely with care homes providing direct contact with them required and making sure all relevant patients had a regularly updated care plan. The practice was waiting for data analysis to be completed by the clinical commissioning group (CCG) to assess the impact on patients.

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

The areas where the provider must make improvements are:

• The provider must mitigate risks to patients. All actions identified as part of their fire risk assessment must be completed, and appropriate fire safety checks must be carried out at the correct intervals.

• The provider must ensure clinical waste is stored securely and not accessible by patients or members of the public.

In addition:

• The provider should review all polices so they contain accurate information and are practice specific.

• The provider should check their guidance relating to complaints is up to date and accurate.

• The provider should put a system in place so all blood test results where the blood test has been carried out in hospital are stored so they are easily accessible to clinicians accessing records.

• The provider should include all partners on their CQC registration.

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

This practice is rated as Good overall.

We first carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. The overall rating for that inspection was inadequate and the practice was placed into special measures.

A further announced comprehensive inspection was carried out on 12 January 2017. During that inspection it was found that improvements had been made. The practice was given an overall rating of good and was taken out of special measures.

The full comprehensive reports on the March 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Leesbrook Surgery on our website at www.cqc.org.uk.

This announced full comprehensive inspection was carried out on 10 November 2017 in accordance with our inspection methodology. The practice is rated as good.

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? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• 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.

• 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.

• 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.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• The provider should ask potential employees about gaps in their employment history.

• The provider should carry out a fire evacuation, and also revert to carrying out weekly fire alarm checks.

• The provider should make further improvements to their administration and documentation. For example, learning from complaints should be documented, meeting minutes should contain enough information for staff and audit programme where audits are repeated to monitor improvement would be helpful.

• The provider should evaluate their policies to avoid duplication and complication.

• The provider should continue the process of having all partners correctly registered.

• The provider should check data protection arrangements, especially relating to computer smart cards and password.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection we spoke with the practice nurse, three doctors, two non-clinical staff and eight patients.

Patients were provided with appropriate information and support to understand the treatment available to them. New patients registered with the practice were assessed and given appropriate advice. Care plans were in place to reduce the risk of patients being admitted to hospital during the winter months. Some formal and informal checks were carried out to monitor the quality of the service. We saw evidence of improvements being made following these checks. .

The examination couches in three of the rooms we looked at had small tears in the vinyl covering. This presented a risk of infection because the covers could not be cleaned effectively. Not all staff had been trained in the prevention and control of infection.

During the recruitment process the identity and work history of new staff was not routinely checked. Criminal Record Bureau (CRB) or Disclosure and Barring Service (DBS) checks had not been carried out for new staff who had direct contact with patients.

The patients we spoke with gave positive comments about the service. They included “I’ve always thought the service was great. Receptionists always look at you and smile, not like at my last practice”, “I’ve seen all the doctors here and they are all brilliant” and “Doctors always explain things in a way I understand. If they didn’t I would ask”.

Letter from the Chief Inspector of General Practice

On 15 March 2016 we carried out a full comprehensive inspection of Leesbrook Surgery. This resulted in two Warning Notices being issued against the provider on 29 April 2016. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 11 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Need for consent, and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Fit and proper persons employed.

On 20 September 2016 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. At this inspection we found that the practice had satisfied the requirements of the Notice.

Specifically we found that:

• Following the previous inspection a GP partner had given awareness training to staff on issues relating to consent. This included awareness of the Gillick competence and The Mental Capacity Act 2005. The Gillick competence is used to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. The Mental Capacity Act 2005 protects people aged 16 and over who lack the capacity to make decisions themselves. Written information was also given to staff.

• Further training was provided to staff in June 2016 by an external provider.

• The understanding of staff on issues relating to consent had been tested following their training. In addition, the member of the nursing team we spoke with had a good understanding of all matters relating to consent.

• Consent and issues relating to the Mental Capacity Act 2005 had been discussed at clinical meetings.

• No new staff had been recruited since the previous inspection. Two new staff were in the process of being recruited. The recruitment procedure was being followed to ensure all required checks and documents were held.

• Relevant information was held for all clinicians. This included a current Disclosure and Barring Service (DBS) check and evidence of professional registration.

The rating awarded to the practice following our full comprehensive inspection on 15 March 2016 remains unchanged. The practice will be re-inspected in relation to their rating in the future.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice