This practice is rated as ‘Requires Improvement’ overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Good

We carried out an unannounced comprehensive inspection at The Practice St Albans on 13 July 2018. This inspection was undertaken to assess changes made, as a result of areas highlighted in our previous report.

We previously inspected The Practice St Albans on 25 April 2016. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at The Practice St Albans on 12 December 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for the practice following the second inspection was requires improvement.

As a result of concerns raised with us, we carried out an unannounced comprehensive inspection on 18 September 2017 to ensure improvements had continued and to look at the areas highlighted to us. As a result of this the practice was rated as inadequate and placed into special measures.

At the latest inspection on 13 July 2018 we found:

• There were adequate systems to assess, monitor and manage risks to patient safety.
• There had been the addition of a local safeguarding lead since our last inspection, however not all staff knew who they were.
• Since the last inspection, there had been a clear division of roles amongst non-clinical staff.
• A central log, which recorded attempts to recall patients for review had been put in place to allow for oversight of all patients with long term conditions.
• The practice had led on a number of initiatives to engage with patients. For example, the mental health lead had developed a ‘Health Thinking Café’
• We spoke with two members of staff about the Accessible Information Standard but neither were aware of it. We asked if there was a practice policy about this, staff told us that they did not think there was.
• There was an effective system of audit work being undertaken and scheduled for the future.
• Staff appraisals were undertaken annually and staff were encouraged and supported to develop their skills and enhance their role.
• Staff treated patients with compassion, kindness, dignity and respect.
• The practice proactively identified carers and supported them. In partnership with the Nottingham Carers Hub, the practice held a ‘Carers Café’ at the surgery to make patients aware what support was available for them. It was planned to be held again in the future, but would be opened up to all carers in the area to improve communication and support.
• The practice had delivered ‘mini-medics training’, which was basic first aid training for children aged 10-12 years old. This helped younger people engage with the surgery and the success of the first programme meant further sessions would be planned in the future.
• The practice worked with the Young Carers Federation to identify younger carers. This included promotional work at a local educational academy.
• The carers lead and reception team offered a form completion service for patients who required additional support.
• There had been an improvement in capacity since our last inspection. For example, at 11am on the day of the inspection there were still four GP appointments available for that day (two of which were bookable online only) and two ANP appointments.
• There was a clear strategy and visions and values which had been communicated with the practice team to ensure individuals understood their contribution to this.
• The practice had developed a supportive and inclusive approach in terms of the leadership of the practice. It was acknowledged that a local clinical lead would benefit the leadership and staff further and this role was at interview stage at the time of the inspection.
• All changes implemented and planned since our last inspection had been driven by the practice manager and supported by the regional team in delivery, however they had been developed in conjunction with all practice staff. We were told by staff that the changes implemented had been seen as a positive transformation benefiting both patients and staff.

The areas where the provider should make improvements are:

• The practice should continue to improve the uptake of annual reviews for patients with a learning disability.
• The practice should continue to improve patient outcomes in relation to the Quality and Outcomes Framework (QOF).
• The practice should improve the way in which it communicates in line with the Accessible Information Standard.
• The practice should consider disability access at the branch site.

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 an announced comprehensive inspection at The Practice St Albans on 25 April 2016. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at The Practice St Albans on 12 December 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for the practice following the second inspection was requires improvement.

As a result of concerns raised with us, we carried out an unannounced comprehensive inspection on 18 September 2017 to ensure improvements had continued and to look at the areas highlighted to us.

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

• Effective systems were in place to report, record and learn from significant events. Learning was shared with staff and external stakeholders where appropriate.
• Staff were aware of current evidence based guidance.
• Training was provided for staff which equipped them with the skills, knowledge and experience to deliver effective care and treatment.
• Staff told us there were often times when there was not enough clinical staff available to meet patient need.
• Facilities at the branch site lacked appropriate levels of cleanliness in line with infection control guidance.
• Patients said they were treated with compassion and dignity, and staff were supportive and respectful in providing care, involving them in care and decisions about their treatment.
• We saw performance in the Quality and Outcomes Framework (QOF) had improved in the latest 2016/17 QOF year, however remained below CCG and national averages in a majority of areas.
• There had been no audits commenced since our previous inspection in December 2016.
• Urgent appointments were available on the same day. However, patients said they had to queue outside the practice to enable them to obtain a same day urgent appointment, often meaning two trips to the practice. Patients said they regularly had to wait a number of weeks for the next available routine appointment.
• Information about services and how to complain was available and investigations were transparent, apologies given where appropriate and the patient was involved in the process.
• There had been some improvement, as well as decline, in the results in the latest national GP patient survey. The practice was aware and had implemented improvement plans.
• The main site had good facilities and was well equipped to treat patients and meet their needs. Services were designed to meet the needs of patients. Oversight of infection control and cleanliness was not as effective at the branch site; however, an upgrade was planned to address this.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.
• However, there was a lack of change resulting from the concerns outlined in previous inspection reports and patient feedback, which showed a lack of progress in the development of the service.
• There was minimal engagement with people who use the services and no detailed response to what patients say to enable improvements.

There were some areas in which the provider must make improvements:

• Ensure arrangements for managing the stock of consumables and appropriate disposal when dates expire.
• Ensure infection prevention and control procedures to ensure improvement in the cleanliness and hygiene at the branch site in line with national guidance.
• Ensure feedback from patients, surveys and reports are acted on and changes implemented.

There were some areas the provider should make improvement:

• Continue to monitor and ensure improvement to national GP patient survey results in relation to access to appointments reduce the need for patients to queue outside the practice.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Practice St Albans on 25 April 2016. Overall the rating for the practice was rated as requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.

We carried out a second announced comprehensive inspection at The Practice St Albans on 12 December 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection is requires improvement.

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

• There was an open and transparent approach to safety within the practice. Effective systems were in place to report, record and learn from significant events. Learning was shared with staff and external stakeholders where appropriate.
• Staff were aware of current evidence based guidance.
• Training was provided for staff which equipped them with the skills, knowledge and experience to deliver effective care and treatment.
• The monitoring of fridges used for the storage of medicines and the checking of out of date dressings required strengthening but this did not create a risk to patients.
• Patients said they were treated with compassion and dignity, and staff were supportive and respectful in providing care, involving them in care and decisions about their treatment.
• Performance in the Quality and Outcomes Framework had declined from the previous year but the practice had implemented plans for improvement since the last inspection.
• Patients told us they were usually able to get an appointment with a GP when they needed one, with urgent appointments available on the same day. However, it could take a long time to get through to reception by phone. The practice had implemented an action plan to improve.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns and learning from complaints was shared with staff and stakeholders.
• Data from the national GP patient survey reflected mixed views about the services provided. The practice were aware and had implemented improvement plans.
• The practice had good facilities and was well equipped to treat patients and meet their needs. Services were designed to meet the needs of patients.
• 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.

However, there were some areas the provider should make improvement:

• Ensure the regular daily monitoring and recording of fridge temperatures at the branch surgery to allow for safe storage of vaccinations.
• Improve arrangements for managing the stock of consumables including the safe disposal of out of date dressings and other expired medical equipment.
• Continue to monitor QOF data in relation to long term conditions and mental health to ensure that the improvements made are being sustained.
• Continue to improve the identification of patients who are carers.
• Continue to monitor and ensure improvement to national GP patient survey in relation to access to appointments.

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 The Practice St Albans on 25 April 2016. Overall the practice is rated as requires improvement.

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

• The provider had an online reporting system which enabled staff to report and record significant events, incidents and near misses. Opportunities for learning from internal incidents were maximised.

• The overall risks to patients were assessed and well managed, with improvements required to ensure the security of prescriptions.

• Additional staff had recently been recruited to mitigate the challenges in recruiting GPs in the local area. This included a pharmacist and an advanced nurse practitioner.

• Staff were supported with induction and training to develop their professional skills and experience.

• Staff used best practice guidance to assess patients’ needs and plan their care. However, data reviewed showed most patient outcomes were marginally in line with or lower than the local and national averages.

• Clinical audits were carried out and we saw evidence of improvements to patient outcomes.

• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.

• We received mixed views regarding the appointment system. Some patients said they did not always find it easy to access the practice by telephone especially in the morning and they sometimes had to wait a “long time” for non-urgent appointments.

• The practice had undertaken two projects to address the challenges associated with access to GP appointments. Some of the positive outcomes achieved for patients included increased GP appointments and reduced numbers of patients not attending appointments.

• Information about services and how to complain was available and easy to understand.

• The practice had a clear vision to deliver high quality care and promote good outcomes for patients. Most staff were clear about the practice vision and their responsibilities in relation to it.

• The arrangements for clinical governance and performance did not always operate effectively and some incidents notifiable to the Care Quality Commission had not been reported as required by law.

• The patient participation group was active, although patients we spoke with were not aware of this group.

The areas where the provider must make improvements are:

• Ensure all notifiable incidents are reported in a timely manner to the Care Quality Commission.

• Take more proactive steps to ensure patients with a learning disability receive an annual health check.

• Ensure the system in place to scan and review correspondence is effective and has clinical oversight.

• Continue taking steps to identify improvements in the delivery of clinical care and patient outcomes.

In addition the provider should:

• Improve security for the issue and tracking of blank prescription forms.

• Improve the membership and visibility of the patient participation group within the practice.

• Improve telephone access and the availability of non-urgent GP appointments.

• Take more proactive steps to promote the identification and review of carers health needs.

• Consider the low patient satisfaction results in respect of GP consultations and identify improvement areas.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice