We carried out an announced comprehensive inspection at Orchard House Surgery on 14 March 2017. We found the practice was good in safe, caring, responsive and well-led and requires improvement in effective. The overall rating for the practice was Good. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Orchard House Surgery on our website at www.cqc.org.uk.

After the inspection in March 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced focussed inspection carried out on 29 March 2018 to confirm that the practice had carried out their plan to meet the improvements we recommended after our inspection on 14 March 2017. This report covers findings in relation to those recommendations. At the March 2017 inspection, we told the practice they should:

• Continue to embed systems to recall and review patients as required.

• Continue to embed the process for on-going updates to staff training.

• Continue to develop the process for identifying and supporting those patients who wish to identify themselves as carers.

The inspection carried out on 28 March 2018 found that the practice had responded to the concerns raised at the March 2017 inspection and were in the process of embedding the changes made. The practice is now rated good for effective with an overall rating of good.

The key question inspected is rated as:

Are services effective? – Good

As part of our inspection process we also look at the quality of care for specific patient population groups. The patient population group inspected is rated as:

People whose circumstances may make them vulnerable – Good

Our key findings were as follows:

• The practice had improved its system to identify and support patients who are also carers.
• The practice was continuing to embed systems to recall and review patients. They had implemented new systems and processes which had resulted in improved Quality Outcome Framework (QOF) results.

• The practice had continued to develop and monitor the process for managing on-going updates for staff training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Orchard House Surgery on 5 July 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Orchard House Surgery on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 14 March 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 a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey published in July 2016 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• 95% of patients described the overall experience of this GP practice as good compared with the CCG average of 84% and the national average of 85%.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with 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.
• A patient participation group had been established.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

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

The provider should:

• Continue to embed systems to recall and review patients as required.
• Continue to embed the process for on-going updates to staff training.
• Continue to develop the process for identifying and supporting those patients who wish to identify themselves as carers.

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

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 Orchard House Surgery on 5 July 2016. Overall the practice is rated as inadequate.

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

• The provider was aware of and complied with the Duty of Candour. The GP encouraged a culture of openness and honesty.
• There was system for reporting and recording significant events. However, reviews, investigations and records of significant events did not always contain dates and timelines.
• Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, the arrangements for managing medicines, including emergency medicines and vaccines were not always effective.
• Patients we spoke with told us they always found the practice clean and had no concerns regarding cleanliness. However, the practice did not always follow national guidance on infection prevention and control.
• The practice was unable to demonstrate that all staff had received Mental Capacity Act training.
• The practice was unable to demonstrate they had safeguarding policies for children or vulnerable adults.
• Staff told us they worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. However, there were no records to confirm this.
• The practice had completed several clinical audits in the last 12 months; two of these were completed audits where the improvements made were implemented and monitored.
• Patients we spoke with told us their dignity, privacy and preferences were always considered and respected.
• Patient records were not always managed in a secure way in that computer system smart cards were left unattended in clinical rooms where the doors were left open.
• There was continuity of care and urgent appointments were available the same day.
• Information about services was available in the waiting room and on the practice website, which also contained a translation service. However, opening times and how to access services outside of opening times were not visible outside the premises.
• There were a range of mechanisms to manage the governance of the practice. However, governance arrangements were not robust or always effectively implemented.
• The principal GP had recognised the need for support and had accessed this from multiple avenues including the Local Medical Committee (LMC), neighbouring GP practices and the clinical commissioning group (CCG). In response, the CCG had provided a temporary practice manager to help maintain the day to day organisation within the practice whilst a permanent practice manager was recruited.

The areas where the provider must make improvements are:

• Ensure there are robust processes, systems and training to support staff in gaining patient consent.
• Ensure safety incidents are well recorded and that actions are taken to reduce the chance of the same thing happening again.
• Ensure all staff have the necessary employment checks including a current Disclosure and Barring Service check and employment and character references.
• Ensure all staff are up to date with attending training courses and that all newly appointed staff receive a local induction program.
• Revise risk assessments and management activities to include all risks to patients, staff and visitors.
• Ensure the practice develops systems and processes to manage infection prevention control; having due regards to National guidance.
• Revise governance processes and ensure that there are sufficient documents to govern activity and that these are reviewed and kept up to date.
• Ensure patient records are kept secure.
• Ensure Department of Health guidance is followed when managing the storage of vaccines.
• Revise medicines management procedures to help ensure vaccines and emergency medicines are in date and that there is a process for managing medicine alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
• Ensure blank prescription forms are stored securely and implement systems to track and monitor their use.

In addition the provider should:

• Review opportunities for patient feedback and how to effectively promote the patient participation group.
• Review how multidisciplinary meetings are recorded.
• Review the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if required.
• Review the complaints recording system to ensure time frames and dates are included.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If sufficient improvements have not been made so a rating of inadequate remains 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice