In November 2018, four local practices joined together and formed a new partnership called Riverport Medical Practice. They became the provider for Orchard Surgery St. Ives and three other branch sites, Park Hall and Northcote House and Fenstanton.

The address and inspection history of each site is;

• Orchard Surgery St. Ives (the registered location), Constable Road, St. Ives, Cambridgeshire. PE27 3ER. Previous inspections were:

A comprehensive inspection was carried out in July 2017 and the practice was rated as good overall. A comprehensive inspection was carried out in November 2016 and the practice was rated as inadequate and placed in special measures.

• Parkhall site, 2C, Parkhall Road, Somersham, Cambridgeshire. PE28 3EU.

A focussed inspection was carried out in December 2016 and the practice was rated as good for providing safe services. A comprehensive inspection was carried out in May 2016 and the practice was rated as good overall and requires improvement for providing safe services.

• Northcote House site, 8 Broad Leas, St Ives, Cambridgeshire. PE27 5PT and Fenstanton site, 7E, High Street, Fenstanton, Cambridgeshire. PE28 9LQ

A comprehensive inspection was carried out in December 2016 and the practice was rated as good overall. A comprehensive inspection was carried out in April 2016 and the practice was rated as inadequate and placed in special measures.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Orchard Surgery St Ives on 21 March 2019 as part of our inspection programme.

At this inspection we found:

• In November 2018 the GP partners acknowledged that as three individual practices they were struggling to meet patient demands and to sustain services, the three practices merged to form a new partnership Riverport Medical Practice. This had resulted in the leaders having confidence to share resources, skills and expertise to benefit patients and staff.
• The practice had met the challenges of implementing a new clinical system to enable all sites to access to the patient records, staff changes and co-ordinated standard working procedures across all sites.
• The management team recognised the significant work that had been undertaken and recognised there were still systems and processes to fully embed and others that required further improvement.
• Staff we spoke with told us they were proud of the improvements the merger had made for their patients. For example, greater skill mix and expertise shared across the sites.
• 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. They recognised that the recording of these events lacked detail to be fully assured that trends would be identified and actions monitored.
• 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.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

We rated the practice as requires improvement for delivering safe services because;

• The system and process to ensure all medicines were stored safely needed to be improved as we found some out of date medicines, gases and equipment. The practice took immediate action to address the issues.
• The system and process to ensure all appropriate emergency medicines were available needed to be improved as we found missing items at two of the sites. The practice took immediate action and obtained them.
• We saw the practice had a programme of training but some staff were overdue training that the practice had deemed mandatory.
• The practice was knowledgeable about the patients on their safeguarding register but they did not have a formalised approach to multi-disciplinary team management of safeguarding concerns.
• We found no concerns relating to infection prevention and control but the policies needed to be improved to ensure all information was easily available to all staff to maintain the standards required.

The areas where the provider must make improvements as they are in breach of regulations 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 are:

• Improve the systems and processes in place to ensure significant events and complaints are recorded in detail to record actions taken, learning identified and to monitor improvements made.
• Review the practice performance, including clinical oversight for exception reporting and consistent coding of medical records to ensure all patients receive appropriate follow up in a timely manner.
• Review and further develop systems and processes to encourage the uptake of the childhood immunisation programme.
• Continue to work with patients to encourage the development of a patient participation group.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Orchard Surgery St Ives on 7 November 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 November 2016 inspection can be found by selecting the ‘all reports’ link for Orchard Surgery – St Ives 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 11 July 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had ensured there was effective leadership capacity to deliver all improvements. A team consisting of GPs, nursing staff and non-clinical staff had met regularly and had delivered improvements.
• The practice had improved the systems to assess, monitor and mitigate risks to patients;

For example, risk assessments undertaken to ensure the health and safety of patients of receiving the care and treatment. The practice had engaged qualified persons to train and support the staff to undertake a comprehensive fire safety assessment and to implement identified improvements.

• Effective systems had been implemented for safeguarding patients from abuse. An accurate, complete, and contemporaneous record was maintained for the patients affected, including relevant information from safeguarding meetings.
• The practice had significantly improved the management of infection prevention and control.
• The security of the dispensary had been reviewed and improvements made.
• Clinical audits had been undertaken and had led to improvements.
• Patient recall systems had been implemented, and coding of patient groups was more consistent, resulting in improved management of patients with long term conditions.
• Systems and process had been implemented to ensure that complaints and feedback were managed effectively and safety had been improved. Minutes of meetings contained sufficient detail to ensure shared learning by practice staff.
• All staff had received an annual appraisal.
• The practice had established a Patient Participation Group.
• Patients said they were treated with compassion, dignity, and respect.
• Patients said they found it easy to make an appointment with a named GP and there were urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice liaised effectively with support organisations and proactively supported vulnerable patient groups.

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

• Monitor the new systems and processes introduced to provide appropriate recall for patients and that coding of medical records is accurate and complete.
• Continue to provide effective clinical leadership to ensure improvements are sustained, and recently introduced systems and processes are embedded.

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

We carried out a comprehensive inspection of Orchard Surgery-St Ives on 7 November 2016. The practice was rated as inadequate overall with ratings of inadequate for providing safe, effective, and well led services, requires improvement for responsive services and good for caring services. As a result of the findings on the day of the inspection the practice was issued with warning notices for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). You can read our findings from our last inspections by selecting the ‘all reports’ link for Orchard Surgery – St Ives on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 28 March 2017 to confirm that the practice had carried out the improvements needed to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 7 November 2016. This report covers our findings in relation to those requirements.

The key findings from our inspection on 28 March 2017 across all the areas we inspected were as follows:

• During this inspection 28 March 2017, we found the practice had recognised the improvements needed following the previous inspection. The GP partners had formed a ‘task’ team to review the report; they had prioritised the improvements needed and had plans in place to deliver these. The task team met regularly and communicated with their colleagues. All practice staff we spoke with told us they had been engaged with the improvement process and had seen significant improvements, in particular with leadership and communication.

• During our inspection on 7 November 2016, we found that the practice had not undertaken any risk assessments for fire safety and had not undertaken actions identified in a report dated May 2004 from the Fire and Rescue Service. During this inspection on 28 March 2017, we found the practice had undertaken a risk assessment, conducted staff training, and some actions had been completed. However, further improvements were needed, for example, the signage to indicate where the oxygen cylinder was stored needed to be put into place.

• During our inspection on 7 November 2016, we found that the practice did not meet the requirements as detailed in the Health and Social care Act (2008); Code of Practice for health and adult social care on the prevention and control of infections and related guidance. During this inspection 28 March 2017, we found that significant improvements had been made including documentation, awareness, staff training, and audits.

• During our inspection on 7 November 2016, we found that the practice did not have a written risk assessment in relation to the security of the dispensary. During this inspection 28 March 2017, we found that significant improvements had been made to the dispensary. All medicines were stored in locked cupboards and access was restricted to the GP partners and dispensary staff.

• During our inspection on 7 November 2016, we found that the practice had not maintained an accurate, complete, and contemporaneous record in respect of each patient. The practice had an inconsistent approach to coding of patients’ medical records. In addition we found that the practice performance in relation to the Quality and Outcome Framework data available from the Health and Social Care Information Centre was significantly lower than the Clinical Commissioning Group (CCG) and England averages. During this inspection on 28 March 2017, the practice demonstrated the improvements they had made, for example, the GP, nurses and administration team had developed new templates to record clinical findings and had introduced a recall system to invite patients in for reviews at the appropriate time.

• During our inspection on 7 November 2016, we found that the practice did not demonstrate clear clinical leadership and did not evidence their working in partnership with other relevant bodies to ensure that safeguarding children and vulnerable adults would keep patients safe from harm. During this inspection on 28 March 2017, we found that there was clear clinical leadership in place, meetings with other professionals such as health visitors and district nurses were recorded, and the information was shared within the practice.

• We found these new systems and processes still needed to be embedded in order to fully assess their appropriateness, workability, and sustainability.

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

Importantly, the provider must:

• Ensure further improvements to the management of fire safety in the practice. Ensure an appropriately trained person reviews the risk assessment and completes all actions identified.

• Ensure that the new systems and process recently introduced to provide appropriate recall for patients and medical records are maintained to provide accurate, complete, and contemporaneous record in respect of each patient.

• Ensure clinical leadership and recorded meetings are embedded to ensure safeguarding of children and adults and that information continues to be shared with and available to all appropriate staff.

In addition the provider should;

• Continue to provide effective clinical leadership to ensure further improvements are made, and recently introduced systems and processes are embedded.

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 Surgery-St Ives on 7 November 2016. Overall the practice is rated as inadequate.

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

• We found that the system in place for reporting and recording significant events and complaints was not sufficient to ensure that all incidences had been recorded, learning from events was shared effectively with the practice team and changes made to improve the service. The opportunities to take early interventions to encourage improvement were missed.
• The patients and practice staff were at risk of harm, as the practice had not undertaken sufficient risk assessments to ensure that they would be kept safe. For example the practice had not undertaken risk assessments for fire or infection control and prevention.

• The practice did not evidence on-going quality improvement activities, such as clinical audits.

• The practice told us that the GPs held discussions with other agencies such as health visitors, however, the practice were only able to evidence two meetings in the past 12 months, these meetings had not been attended by the GPs but by a non-clinical staff member, the minutes lacked sufficient detail to ensure that any relevant information was shared with the appropriate professionals.

• The practice lacked GP leadership, and a cohesive team approach. Some areas of the practice performance were insufficiently supported to ensure safe and effective care and treatment for patients. For example, data from the quality and outcome framework was significantly lower than the CCG and national averages in some areas.

• Practice staff had not received any annual appraisals.

• Patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.

• The practice reception team had developed an effective system to ensure that all patients test results were received by the practice in a timely manner and when problems occurred they were proactive and investigated the delay.

The areas where the provider must make improvements are:

• The practice must assess the risks to the health and safety of patients of receiving the care and treatment and do all that is reasonably practicable to mitigate any such risks.

• Ensure that risk assessments for fire safety are undertaken and that any identified actions are completed in a timely manner and formally risk assessing access to the dispensary.

• Ensure that the practice meets the requirements detailed in the Health and Social Care Act 2008; Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

• Ensure there are effective systems in place for safeguarding patients from abuse.

• Undertake on-going quality improvement activities, such as clinical audits, with suitable follow up to ensure improvements have been achieved.

• Ensure that an accurate, complete, and contemporaneous record is maintained for every patient including relevant information from safeguarding meetings.

• Ensure there is effective leadership capacity to deliver all improvements.

The areas where the provider should make improvement are:

• Maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.

• Review systems and process to ensure that complaints and feedback are managed effectively and safely. Minutes of meetings should contain sufficient detail to ensure shared learning by practice staff.

• The practice should improve the systems to assess, monitor and mitigate risks to patients for example, implement logs for recording safety alerts, who received or actions taken and to give oversight to ensure that all staff received the appropriate training for their roles or needs.

• The practice should ensure an annual appraisal enhancing the opportunity to discuss their personal development is given to all members of staff.

• The practice should continue to make efforts to establish an active Patient Participation Group

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate 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.

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 a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice