Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Myrtle House Surgery on 19 January 2017. The overall rating for the practice was requires improvement with the key questions of safe and well-led rated as requires improvement. Action was required to mitigate identified risks and to review and improve the governance arrangements to ensure they were comprehensive. Systems in place also required review to ensure appropriate follow-up action was taken for patients identified as vulnerable. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Myrtle House Surgery website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 July 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 19 January 2017. 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. Our key findings were as follows:

• We saw evidence at this inspection that records of incidents were now in place and there was evidence of shared learning from these events including formal meetings and documentation of discussions.

• At this inspection, we saw evidence that the practice Health and Safety policy had been updated and a comprehensive risk assessment had been undertaken. All identified risks have been mitigated.
• We found at this inspection that an IPC audit had taken place, action taken as required and staff attended training in May 2017.
• At this inspection, we found that systems have been reviewed and all patients identified as vulnerable had an alert on their records.
• We saw evidence at this inspection that patient outcomes are now under ongoing review and achievement on the Quality and Outcomes Framework (QOF) had improved substantially.
• We found evidence of monitoring of staff updating their knowledge as policies were reviewed.
• We saw at this inspection that a training matrix had been introduced to monitor staff training. Personnel records remained poorly organised; however we saw evidence that this had been improved within two days of our inspection.
• At this inspection we saw that all clinical audit activity had been captured and that new protocols had been introduced to improve care and treatment.
• At this inspection, the practice showed us evidence of discussions regarding assisting patients who had a hearing loss. All staff had attended a meeting to discuss how to access translation services.

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 Myrtle House Surgery on 19 January 2017. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, records maintained by the practice did not include sufficient detail to demonstrate improvement actions were monitored and reviewed to ensure they were adequate and effective.
• Risk management activity was not consistently and fully completed. For example risks related to fire and electrical safety had been identified in 2016 but limited action had been taken to mitigate those risks.
• Infection prevention and control (IPC) activity was undertaken within the practice supported by a practice policy and regular audits. However, audit activity was not comprehensive and audit records did not detail sufficient information to demonstrate action was taken when areas for improvement were identified.
• There was limited evidence of IPC training for staff.
• Systems in place to ensure appropriate follow-up action was taken for patients identified as vulnerable within practice records following receipt of notifications were not sufficient.
• Data showed patient outcomes were variable when compared to the national average. However, a good understanding of performance was maintained within the practice and there was evidence of continuing improvement.
• Patient’s feedback was generally good and patients said they were treated with compassion, dignity and respect.
• The practice had a number of policies and procedures to govern activity, but we noted compliance with practice policy was not always consistent.

The areas where the provider must make improvements are:

• Take action to mitigate identified risks and review and improve the governance arrangements for the identification, assessment and management of health and safety risks to ensure they are comprehensive and complete.

• Review the systems in place to ensure appropriate follow-up action is taken for patients identified as vulnerable within practice records following receipt of notifications.

In addition the provider should:

• Implement a revised system to support the completion of staff training and maintenance of associated records.
• Ensure staff have received infection prevention and control training as appropriate to enable them to carry out their individual roles and responsibilities.
• Create and maintain records to support the management of clinical audit activity and that demonstrate the implementation of improvement actions.
• Have a system in place that details the actions taken in response to all alerts issued by external agencies.
• Implement a system to support compliance with practice policies and procedures.
• Consider the installation of a hearing loop and ensure all staff are aware of the availability of translation services within the practice.
• Review the practice Service Continuity plan to ensure it details appropriate direction and information relevant to Myrtle House Surgery.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice