This practice is rated as Good overall. (Previous rating August 2017 – Good overall)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Triangle Group Practice on 25 September 2018 to follow up breaches of regulation identified at our previous inspection carried out on 09 August 2017. At our last inspection the provider was rated as requires improvement for key question; Are services Safe? We issued a requirement notice in respect of a breaches of regulation 12 of the Health and Social Care Act Regulations 2014. The concerns related to the arrangements in respect of infection control management which were not adequate.

In addition to the breaches of regulation, we also made recommendations of other actions the practice should take.

At this inspection we found:

• Action had been taken on most of the issues identified at the previous inspection; those we required and those we recommended.
• Systems for managing infection control had been improved. There was a suite of infection control policies in place. Risks associated with the control and spread of infections were adequately assessed in most areas.
• The practice had clear 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 system in place to review and update policies, and staff were aware of the policies in place and how to access them. However, the practice was not consistently following its own policies and procedures.
• The practice understood the learning needs of staff and had created a matrix to monitor staff training. However, the practice had not kept an up to date record of the mandatory training completed by the locum.
• The practice carried out staff checks at the time of recruitment. There was evidence of checks of professional registration in the staff files we checked.
• 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.
• Two audits had been repeated and there was some evidence that clinical audit was leading to quality improvement.
• 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. Patient feedback on the day of the inspection was largely positive.

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

• Ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Further details can be found in the requirement section at the end of the report.

The areas where the provider should make improvements are:

• Continue with work to improve the uptake of childhood immunisations and cervical screening.
• Take action to promote and monitor social prescribing and signposting for patients.
• Consider ways to promote feedback from staff and patients and monitor it.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We inspected this practice in February 2014, before ratings were introduced, and found issues with arrangements to prevent and control the spread of infection, with access to emergency medicines and with how medicines stored in the practice. We checked in September 2014 and found that the provider had made the required improvements.

We carried out an announced comprehensive inspection at Triangle Group Practice on 24 August 2016.

We rated the practice as inadequate for providing safe services as the arrangements in respect of infection control management, vaccine management, keeping people safe from abuse, risk management and arrangements for emergencies were not adequate. The system for reporting and learning from serious incidents was not clear. There was not a consistent failsafe system to ensure that patients referred to hospital for urgent consultations received a timely appointment.

We rated the practice as requires improvement for providing effective and well led services:

• Staff had not all completed mandatory training and improvements were needed to how clinical audit was used.
• Consent was not being recorded appropriately and some aspects of the practice’s care of patients with diabetes, as reflected in the Quality and Outcomes Framework were below average.
• Arrangements to monitor and improve quality and identify risk were not effective.
• There was no system to ensure that actions agreed at clinical meetings were completed.
• Audits were not being repeated to check for improvement.
• Many of the practice policies were overdue a review. Staff were not aware of some policies or could not locate them.

Under 1% of the practice population had been identified as carers, so that they could be offered information, advice and support.

The overall rating for the practice was requires improvement.

The previous reports can be found by selecting the ‘all reports’ link for Triangle Group Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 9 August 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• Action had been taken on all of the issues identified at the previous inspection; those we required and those we recommended.
• Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions had been tightened, with stronger arrangements in place to keep people safe from abuse, address fire and other risks and to take action in the event of medical emergencies. Arrangements for vaccine management and infection control had been improved, but were not fully embedded.
• There was a clear system for learning from significant events, and there was an effective system to follow up on referrals for urgent consultations received a timely appointment and that results were received, reviewed and acted upon swiftly.

• 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 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• 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.
• There was a system in place to review and update policies, and staff were aware of the policies in place and how to access them.
• Arrangements were in place to ensure that actions from all meetings were follow up.
• Two audits had been repeated and there was some evidence that audit was leading to quality improvement.
• More patients had been identified as carers, so that they could be offered information, advice and support.

However, there were some areas that required further attention:

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients. Further details can be found in the requirement section at the end of the report.

In addition the provider should:

• Monitor the improvements made to ensure that they are consistently embedded. For example, vaccine fridge checks, the new consent form, and checks of the defibrillator.
• Consider ways to improve the uptake of childhood immunisations.

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 Triangle Group Practice on 24 August 2016. Overall the practice is rated as requires improvement.

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

• There was a policy in place for reporting and recording significant events, but this was not being followed consistently; and recording did not always show sufficiently thorough analysis.

• The systems to keep patients safe and safeguarded from abuse were not well defined or embedded. The practice policy was inaccurate, incomplete and staff were not able to locate it when we asked. Of the GPs, only the lead GP for had completed recent appropriate training, and when the practice received safeguarding information from other healthcare professionals, this was not being used effectively to keep people safe. Staff acting as chaperones, and a nurse had not had a Disclosure and Barring Service (DBS) check carried out by the practice.
• Overall, risks to patients were not well assessed and well managed. Arrangements for preventing and controlling infections were not effective, with limited audit and no mechanism to ensure that actions identified had been completed. The practice had a policy relating to fire safety, but this had not been reviewed since 2011 and the fire risk assessment was overdue. Not all staff had had fire training. There were no arrangements to monitor the use of prescription forms and pads, including those for controlled drugs. The practice did not have the expected equipment to respond to emergencies and major incidents.

• 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.
• There was quality improvement activity, but audits hadn’t been repeated to check that improvement had been made.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients 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.
• The provider was aware of and complied with the requirements of the duty of candour.
• There were no systems in place to ensure that policies were reviewed and updated.

The areas where the provider must make improvement are:

• Strengthen arrangements for assessing and mitigating risks, including infection prevention and control (specific training for staff, comprehensive audit and follow up of issues), the vaccine cold chain (fridge stock management, and ensuring action is taken in response to temperature checks), fire risk assessment and training and the monitoring of prescription forms and pads. Ensure there are adequate arrangements to manage medical emergencies; either obtain a defibrillator and medicines to deal with a range of medical emergencies, or justify this decision with a robust risk assessment.

• Ensure arrangements are in place to keep children safe: update and complete the practice policy, ensure that all staff are aware of the policy and have had appropriate training. Ensure that information regarding vulnerable people who may be at risk of abuse is recorded in a way that it is easily accessible to all clinicians, including locum staff.

• Develop quality improvement process, to include clinical audit, to improve outcomes for patients. Establish mechanisms to review and update practice policies; ensure that staff are aware of policies and how to access them.

• Ensure that all clinical staff receive DBS checks. Staff undertaking chaperoning should receive DBS checks unless a risk assessment indicates these are not required.

The areas where the provider should make improvement are:

• Review significant incident management; including how to ensure that incidents are correctly identified, analysed and recorded.

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Consider developing a training policy that details the training required for each role and the training intervals. Ensure that all staff complete mandatory training, including information governance, and consider providing basic life support training for all staff (not just clinical staff) annually.

• Consider ways to improve the management of patients with diabetes, to improve antibiotic prescribing and the uptake of childhood immunisations.

• Review arrangements for taking consent for surgical procedures to ensure that patients are fully informed and that the decision is fully documented.

• Consider mechanisms to ensure that actions agreed at clinical meetings are carried out.

• Review the chaperone policy and ensure that this is consistent with information provided to patients.

• Implement a consistent failsafe system to ensure that patients who have been referred to hospital for urgent tests receive a timely appointment.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We carried out this inspection to ensure that the provider had completed the required improvements and addressed the areas of non-compliance found at our inspection on the 07 February 2014.

At the inspection on the 04 September 2014 we found that the provider had made the required improvements to ensure they were meeting this essential standard.

We did not speak with patients during this inspection.

We found that people were treated with dignity and respect and that individual needs were met in relation to their care and treatment. Most people we spoke with told us they were happy with the care and treatment they received when visiting the practice.

We saw that systems were in place to promote safe practice and continuity of care. Records we viewed detailed patients medical history, treatment and referrals made to a health care specialist.The provider did not always protect people using the service from the risk of infection, beause they did not follow their practice policy or local guidance rearding infection control processes.

Medicines were not always, stored, monitored, checked or disposed of appropriately.

There were effective recruitment processes in place and appropriate checks were undertaken before staff began work. There were systems in place to monitor the quality of the service. The service listened to the views of people using the service to make the necessary improvements, for example updating the practice website regularly. The practice had a process and policy for making a complaint. The practice handled and managed complaints appropriately.