Northcote House Surgery NewApproachComprehensive Report ... · •...

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Inadequate –––

Are services safe? Inadequate –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Inadequate –––

NorthcNorthcototee HouseHouse SurSurggereryyQuality Report

8 Broad LeasSt IvesCambsPE27 5PTTel: 01480 461873Website: http://www.northcotehousesurgery.co.uk

Date of inspection visit: 20 April 2016Date of publication: This is auto-populated when thereport is published

1 Northcote House Surgery Quality Report This is auto-populated when the report is published

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 7

What people who use the service say 11

Areas for improvement 11

Detailed findings from this inspectionOur inspection team 13

Background to Northcote House Surgery 13

Why we carried out this inspection 13

How we carried out this inspection 13

Detailed findings 15

Action we have told the provider to take 26

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Northcote House Surgery on 20 April 2016. Overall thepractice is rated as inadequate.

Our key findings across all the areas we inspected were asfollows:

• Patients were at risk of harm because systems andprocesses were not in place to keep them safe. Forexample, actions identified to address concerns withinfection control practice had not been taken.

• Significant events were not adequately managed orrecorded.

• Patients were positive about their interactions withmost staff and said they were treated with compassionand dignity by those staff members.

• The practice’s branch location in Fenstanton had goodfacilities and was well equipped to treat patients andmeet their needs.

• The practice had a clear leadership structure, butinsufficient leadership capacity and limited formalgovernance arrangements.

• The provider was aware of and complied with therequirements of the Duty of Candour.

The area where the provider must make an improvementis:

• Ensure appropriate security systems are in place sothat only authorised practice staff can access thedispensary.

• A risk analysis must be carried out on the safetransport and storage of medicines to the branchsurgery at Fenstanton.

• Ensure all emergency prescriptions issued are signedby a GP before being issued to a patient.

• Ensure that staff caring for patients have undergone aDisclosure and Barring Service check (DBS).

• Ensure all staff training deemed mandatory by thepractice is up to date, including training forsafeguarding.

Summary of findings


• Ensure all policies, procedures and guidance are up todate so that staff are able to operate in accordancewith up to date procedures.

• The provider must have an adequate infection controlsystem in place to ensure that patients and staff areadequately protected.

• The practice must comply with relevant Patient SafetyAlerts issued from the Medicines and Healthcareproducts Agency (MHRA) and through the CentralAlerting System (CAS).

The areas where the provider should makeimprovements are:

• Improve confidentiality at the front desk and in thehallway at the St Ives location as well as for phonecalls.

• Ensure thermometers used to record refrigerator androom temperatures where medicines are stored arevalidated before use to ensure their accuracy. Inaddition, the automated external defibrillator must bechecked and serviced at regular intervals and at leastannually.

• Ensure actions from the legionella assessment areundertaken.

• Ensure effective control of substances hazardous tohealth is in place.

• Ensure blank prescription forms are kept securely at alltimes.

• Significant events, complaints, (medicines) auditresults and the associated learning should be sharedacross practice staff teams to ensure that lessons areembedded and to prevent reoccurrence of errors.

• Ensure staff receive timely appraisals and support.• Ensure chaperone training is available for all staff

undertaking such duties.

I am placing this practice in special measures. Practicesplaced in special measures will be inspected again withinsix months. If insufficient improvements have been madeso a rating of inadequate remains for any populationgroup, key question or overall, we will take action in linewith our enforcement procedures to begin the process ofpreventing the provider from operating the service. Thiswill lead to cancelling their registration or to varying theterms of their registration within six months if they do notimprove.

The practice will be kept under review and if neededcould be escalated to urgent enforcement action. Wherenecessary, another inspection will be conducted within afurther six months, and if there is not enoughimprovement we will move to close the service.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as inadequate for providing safe services.

• The system in place for reporting and recording significantevents was not robust and did not provide assurances that thepractice was able to investigate, review, share and learn fromincidents.

• When there were unintended or unexpected safety incidents,patients received reasonable support, truthful information, averbal and written apology. They were told about any actions toimprove processes to prevent the same thing happening again.However, learning was not always shared within the practice.

• The practice did not have clearly defined and embeddedsystems, processes and practices in place to keep patients safeand safeguarded from abuse. The safeguarding policy was notup to date and there were gaps in safeguarding training forvarious members of staff other than GPs.

• Infection control management processes were not robust andthere was no clear leadership on these.

• Risks to patients had been assessed and partially managed butimprovement was needed in addressing further findings as wellas outcomes from the legionella assessment. There was noevidence that control of substances hazardous to health(COSHH) was in place.

• Recruitment checks including checks with the Disclosure andBarring Service were not consistently undertaken. We sawevidence that one clinical member of staff had not undergone aDBS check.

Inadequate –––

Are services effective?The practice is rated as requires improvement for providing effectiveservices.

• Data from the Quality and Outcomes Framework showedpatient outcomes were overall below local and nationalaverages in 2014/15 but this had significantly improved in 2015/16, but this data was not yet verified at the time of inspecting orreporting.

• Staff assessed needs and delivered care in line with currentevidence based guidance.

• The practice undertook clinical audits that demonstratedquality improvement.

Requires improvement –––

Summary of findings


• Staff had the skills, knowledge and experience to delivereffective care and treatment but were not supported enoughwhen needing to undertake mandatory training.

• Not all staff had received up to date appraisals. We notedappraisals were due for five members of staff.

• Staff worked with multidisciplinary teams to understand andmeet the range and complexity of patients’ needs.

Are services caring?The practice is rated as good for providing caring services.

• Data from the National GP Patient Survey published in January2016 showed patients rated the practice higher than others forseveral aspects of care.

• Information for patients about the services available was easyto understand and accessible.

• We saw staff treated patients with kindness and respect, andmaintained patient and information confidentiality.

• The front desk did not provide sufficient confidentiality withlimited queuing space and the adjacent waiting room beingwithin earshot; phone calls were being answered at the frontdesk and could be overheard.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services.

• Practice staff reviewed the needs of its local population andengaged with the NHS England Area Team and ClinicalCommissioning Group to secure improvements to serviceswhere these were identified.

• Patients said they found it easy to make an appointment with aGP and there was continuity of care, with urgent appointmentsavailable the same day.

• The practice had good facilities and was well equipped to treatpatients and meet their needs.

• Information about how to complain was available and easy tounderstand and evidence showed the practice respondedquickly to issues raised. Learning from complaints was notshared with staff and other stakeholders.

Good –––

Are services well-led?The practice is rated as inadequate for being well-led.


Summary of findings


• The practice had a vision to deliver high quality care andpromote good outcomes for patients and staff were clear abouttheir responsibilities in relation to this but there was nobusiness plan incorporating a clear vision and strategy.

• There were structures and procedures in place but these werenot robust enough to ensure the practice had an effectivegovernance framework to support the delivery of the strategyand good quality care.

• There was a clear leadership structure but not all staff feltsupported by management.

• The practice had a number of policies and procedures togovern activity, but these were three years old and had notbeen reviewed since.

• The provider was aware of and complied with the requirementsof the Duty of Candour.

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• The practice offered proactive, personalised care to meet theneeds of the older people in its population.

• The practice was responsive to the needs of older people, andoffered home visits and urgent appointments for those withenhanced needs.

• Nationally reported data from 2014/15 showed that outcomesfor patients for some conditions commonly found in olderpeople, including osteoporosis: secondary prevention offragility fractures, were below local and national averages. Wesaw data that was not yet publicly available or validated whichindicated that this had improved for 2015/16.


People with long term conditionsThe practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• Nursing staff had lead roles in chronic disease management,and patients at risk of hospital admission were identified as apriority.

• The practice participated in the Quality and OutcomesFramework (QOF - is a voluntary incentive scheme for GPpractices in the UK. The scheme financially rewards practicesfor managing some of the most common long-term conditionse.g. diabetes and implementing preventative measures. Theresults are published annually). The practice used theinformation collected for the QOF and performance againstnational screening programmes to monitor outcomes forpatients. In 2014/2015 performance for asthma relatedindicators was higher compared to the CCG and nationalaverage. With the practice achieving 100%, this was 2.4% abovethe CCG average and 2.6% above the national average.

• Performance for diabetes related indicators was lowercompared to the CCG and national average. With the practiceachieving 87.6%, this was 1.9% below the CCG average and1.6% below the national average.


Summary of findings


• Performance for heart failure related indicators was highercompared to the CCG and national average. With the practiceachieving 100%, this was 4.2% above the CCG average and 2.1%above the national average.

• Longer appointments and home visits were available whenneeded.

• For those patients with the most complex needs, the named GPworked with relevant health and care professionals to deliver amultidisciplinary package of care.

Families, children and young peopleThe practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• Immunisation rates were relatively high for all standardchildhood immunisations.

• Some patients told us that children and young people were notalways treated in an age-appropriate way but we did notobserve this during the inspection.

• The practice’s uptake for the cervical screening programme was80.0%, which was in line with the national average.

• Appointments were available outside of school hours and thepremises were suitable for children and babies.

• We saw positive examples of joint working with midwives.


Working age people (including those recently retired andstudents)The practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• The needs of the working age population, those recently retiredand students had been identified and the practice had adjustedthe services it offered to ensure these were accessible, flexibleand offered continuity of care.

• The practice was proactive in offering online services as well ashealth promotion and screening that reflects the needs for thisage group.

• The practice offered early morning nurse appointments onTuesday and Thursday morning between 7am and 8am. Thepractice had also provided several Saturday morning sessionswith both GP and nurse appointments over the previous yearbut this was not a regular occurence.


Summary of findings


People whose circumstances may make them vulnerableThe practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• The practice held a register of patients living in vulnerablecircumstances, including those with a learning disability.

• The practice offered longer appointments for patients with alearning disability.

• The practice regularly worked with multi-disciplinary teams inthe case management of vulnerable people.

• The practice informed vulnerable patients about how to accessvarious support groups and voluntary organisations.

• The practice kept a register of patients that were carers.• GPs carried out home visits for patients with palliative care

needs.• Staff knew how to recognise signs of abuse in vulnerable adults

and children. Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguarding concernsand how to contact relevant agencies in normal working hoursand out of hours. .

• The practice carried out annual health checks for people with alearning disability and 15 out of 17 of these patients hadreceived a review since April 2015.


People experiencing poor mental health (including peoplewith dementia)The practice is rated as requires improvement in the effectivedomain and inadequate in the domains of safe and well-led. Theconcerns which led to these ratings apply to everyone using thepractice, including this population group.

• 94.1% of patients with schizophrenia, bipolar affective disorderand other psychoses had a comprehensive care plan, whichwas 7.1% above the CCG average and 5.8% above the nationalaverage. The exception reporting for this indicator was 10.5%,which was below the CCG average and national average.

• The practice regularly worked with multi-disciplinary teams inthe case management of people experiencing poor mentalhealth, including those with dementia.

• The practice carried out advance care planning for patientswith dementia.

• The practice had told patients experiencing poor mental healthhow to access various support groups and voluntaryorganisations.


Summary of findings


• The practice had a system in place to follow up patients whohad attended accident and emergency where they might havebeen experiencing poor mental health.

• Staff had a good understanding of how to support patients withmental health needs and dementia. The practice had 18registered patients with dementia of which 17 had received anannual review since April 2015.

• 19 of 25 patients with mental health needs had a care reviewrecorded since April 2015.

Summary of findings


What people who use the service sayThe National GP Patient Survey results were published inJanuary 2016. The results showed the practice wasperforming above or line with local and nationalaverages. 252 survey forms were distributed and 110 werereturned. This was a 44% response rate.

• 96% found it easy to get through to this surgery byphone compared to the local average of 75% andnational average of 73%.

• 84% were able to get an appointment to see or speakto someone the last time they tried compared to thelocal average of 87% and national average of 85%.

• 87% described the overall experience of their GPsurgery as good compared to the local average of 86%and national average of 85%.

• 73% said they would definitely or probablyrecommend their GP surgery to someone who has justmoved to the local area compared to the local averageof 80% and a national average of 78%.

As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection;

we collected 14 completed cards. Nine of the commentcards we received contained positive and complimentarypatient views about the service, one card containednegative comments regarding care and referrals received,two cards contained comments that a high staff turnoverwas evident but were positive about the care received,one card contained negative comments on a GP comingacross as uncaring and positive comments on another GPcoming across very good and one card containedcomments that service was not bad but it was difficult tosee a GP of choice.

We spoke with five patients who provided varyingresponses in being able to get an appointment with onestating it could be difficult and three stating it was easy.They told us they felt the practice offered a good serviceand that staff were polite, helpful, caring and treatedthem with dignity and respect but one patientcommented that the lead GP sometimes came acrossrude.

Areas for improvementAction the service MUST take to improve

• Ensure appropriate security systems are in place sothat only authorised practice staff can access thedispensary.

• A risk analysis must be carried out on the safetransport and storage of medicines to the branchsurgery at Fenstanton.

• Ensure all emergency prescriptions issued are signedby a GP before being issued to a patient.

• Ensure that staff caring for patients have undergone aDisclosure and Barring Service check (DBS).

• Ensure all staff training deemed mandatory by thepractice is up to date, including training forsafeguarding.

• Ensure all policies, procedures and guidance are up todate so that staff are able to operate in accordancewith up to date procedures.

• The provider must have an adequate infection controlsystem in place to ensure that patients and staff areadequately protected.

• The practice must comply with relevant Patient SafetyAlerts issued from the Medicines and Healthcareproducts Agency (MHRA) and through the CentralAlerting System (CAS).

Action the service SHOULD take to improve

• Improve confidentiality at the front desk and in thehallway at the St Ives location as well as for phonecalls.

• Ensure thermometers used to record refrigerator androom temperatures where medicines are stored arevalidated before use to ensure their accuracy. Inaddition, the automated external defibrillator must bechecked and serviced at regular intervals and at leastannually.

• Ensure actions from the legionella assessment areundertaken.

Summary of findings


• Ensure effective control of substances hazardous tohealth is in place.

• Ensure blank prescription forms are kept securely at alltimes.

• Significant events, complaints, (medicines) auditresults and the associated learning should be sharedacross practice staff teams to ensure that lessons areembedded and to prevent reoccurrence of errors.

• Ensure staff receive timely appraisals and support.• Ensure chaperone training is available for all staff

undertaking such duties.

Summary of findings


Our inspection teamOur inspection team was led by:

A CQC lead inspector. The team included a GPspecialist adviser, a practice manager specialist adviserand a CQC medicine optimisation inspector.

Background to NorthcoteHouse SurgeryNorthcote House Surgery is situated in St Ives,Cambridgeshire and has a branch surgery in the nearbyvillage of Fenstanton.The practice provides services forapproximately 3800 patients across both sites. The practicedispenses medications to patients. The practice holds aGeneral Medical Services contract with NHSCambridgeshire and Peterborough CCG.

According to Public Health England, the patient populationhas a higher than average number of patients aged 45 to 69compared to the practice average across England. It has alower proportion of patients aged 35 and below comparedto the practice average across England. Income deprivationaffecting children and older people is lower than thepractice and the England average. The overall level ofdeprivation is in the least deprived decile nationally.

The practice team consists of a sole GP lead who is maleand one salaried female GP. The nursing team consists ofthree practice nurses and a health care assistant. Theclinical staff is supported by a team of dispensary,secretarial and reception staff led by a practice manager.

The practice’s opening times at the time of the inspectionwere 8am to 6pm Monday to Friday. Extended hours

appointments were offered on Tuesday and Thursdaymorning between 7am and 8pm but were for nurseappointments only. During out-of-hours GP services wereprovided by Urgent Care Cambridge.

Why we carried out thisinspectionWe inspected this service as part of our newcomprehensive inspection programme. We carried out acomprehensive inspection of this service under Section 60of the Health and Social Care Act 2008 as part of ourregulatory functions. The inspection was planned to checkwhether the provider is meeting the legal requirements andregulations associated with the Health and Social Care Act2008, to look at the overall quality of the service, and toprovide a rating for the service under the Care Act 2014.

How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 20April 2016. We:

• Spoke with a range of staff and spoke with patients whoused the service.

• Observed how patients were being cared for and talkedwith carers and/or family members

• Reviewed an anonymised sample of the personal careor treatment records of patients.

• Reviewed comment cards where patients and membersof the public shared their views and experiences of theservice.

NorthcNorthcototee HouseHouse SurSurggereryyDetailed findings


To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services were provided forspecific groups of people and what good care looked likefor them. The population groups are:

• Older people

• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

Detailed findings


Our findingsSafe track record and learning

The practice did not have a robust system in place forreporting and recording significant events. Staff told us theywould inform the practice manager of any incidents, andthere was a recording form available. When there wereunintended or unexpected safety incidents, patientsreceived reasonable support, truthful information, a verbaland written apology and were told about any actions toimprove processes to prevent the same thing happeningagain. However, we found that reporting was low with onlythree incidents reported in the previous 12 months. We sawevidence of, and were verbally told by staff about incidentsthat had occurred in the practice over the previous fewmonths which had not been recorded as significant eventbut should have been. For example several incidentsrelating to security breaches in the dispensary. When wereviewed the practice’s policy on significant event recordingwe found this was adequate and included appropriatecriteria for incidents that were expected to be included. Butwe found that recordings did not reflect the policy.Significant events had not been reviewed on a regularbasis; the practice explained that this was due to recenthigh staff turnover. This was in contradiction to thepractice’s policy and regulatory requirements. Any learningfrom significant events was not shared with the staff in thepractice unless they had been directly involved. Howeverdue to the reduced number of recorded incidents this wasdifficult to establish.

Safety was monitored using information from a range ofsources, including National Institute for Health and CareExcellence (NICE) and guidance alerts from the Medicinesand Healthcare products Regulatory Agency (MHRA). Theinformation was monitored by designated members of staffand shared with other staff electronically. When we askedstaff who was responsible for this we did not receive aconsistent answer which indicated that the procedures andcommunication processes for alerts and updates were notrobust.

We found gaps in the practice’s records to demonstratethat alerts and updates had been actioned. For examplethe practice were unable to provide evidence to show thata recent alert relating to GPs undertaking home visits hadbeen reviewed and actions taken. There was no record toshow which staff had received relevant updates and alerts

which meant that the practice could not reassure itself thatadequate action was being taken to keep patients safe. Wesaw that the practice kept a library of hard copies of alertsand updates which were available to staff.

Overview of safety systems and processes

The practice had systems, processes and practices in placeto keep people safe but these were not clearly defined andembedded, they included:

• Arrangements were in place to safeguard children andvulnerable adults from abuse that reflected relevantlegislation and local requirements. The policies wereavailable to all staff in the main practice but when weasked staff in the branch surgery they were not able tofind them at short notice. They did have direct access tothe CCG’s safeguarding protocols and guidance. We sawthat the safeguarding policy had not been reviewedsince 2014 and could therefore not be assured that itscontent was up to date. Staff were able to show ussafeguarding protocol cards that were present in thetreatment and consultation rooms. There was a leadmember of staff for safeguarding and staff we spokewith knew who it was. The GPs attended safeguardingmeetings and worked with other agencies whenrequired and staff demonstrated they understood theirresponsibilities. Evidence we reviewed did not assure usthat all staff, both clinical and non-clinical, had receivedsafeguarding training appropriate for their role. GPswere trained to Safeguarding Level 3 for children andvulnerable adults.

• Notices throughout the practice advised patients thatchaperones were available. Nurses or health careassistants acted as chaperones if required. All memberof staff who acted as chaperones were trained for therole but we saw that one clinical member of staff hadnot received a Disclosure and Barring Service check(DBS checks identify whether a person has a criminalrecord or is on an official list of people barred fromworking in roles where they might have contact withchildren or adults who may be vulnerable).

• We observed the premises to be clean and tidy. We wereinformed by the practice manager that a practice nursewas the infection prevention and control (IPC) clinicallead but when asked, this member of staff was notaware of this. We saw no evidence that the practiceliaised with the local IPC teams to keep up to date withbest practice. There was an IPC protocol in place but

Are services safe?



evidence indicated that only four members of staff hadreceived up to date training. We saw evidence that anannual IPC audit was undertaken the day prior to ourinspection and actions had been identified as a resultbut due to this audit being recent no actions were yetundertaken. We were informed that IPC audits wereundertaken annually except for the previous year butthere were no records available to support this. We sawthat waste segregation and labelling took placeappropriately and appropriate standards of cleanlinessand hygiene were followed. The practice’s branchsurgery had recently been refurbished and we found thisto be very clean and fit for purpose.

• Recruitment checks were mostly carried out and stafffiles we reviewed showed that most appropriaterecruitment checks had been undertaken prior to staff’semployment. For example, references, qualificationsand registration with the appropriate professional body.However, we found that for one clinical member of staffthere was no evidence of a DBS check being done. Thepractice manager explained that as a rule DBS checkswere not carried out for non-clinical staff but there wereno risk assessments in place to determine the need forthese staff members having a DBS. The practicemanager explained that they would undertake DBSchecks or risk assessments immediately after theinspection.

• Arrangements were in place for planning andmonitoring the number of staff and skill mix of staffneeded to meet patients’ needs. There was a rotasystem in place for all the different staffing groups toensure that enough staff were on duty.

• There were procedures in place for monitoring andmanaging risks to patient and staff safety. There was ahealth and safety policy available which identified localhealth and safety representatives. The practice hadundergone an externally led risk assessment in October2015 which had highlighted several areas that requiredattention. We saw evidence that some areas wereaddressed but not all. The practice manager explainedthe practice was still in the process of addressing someof the actions. The practice had a variety of other riskassessments in place to monitor safety of the premises,such as an infection control manual, but this dated backto 2011 and referred to out of date guidance. When weasked to see the documentation on the control ofsubstances hazardous to health the practice was unable

to provide these. The practice had undertaken anexternal risk assessment for legionella (legionella is aterm for a particular bacterium which can contaminatewater systems in buildings) in 2013. The assessment hadraised several recommendations that neededaddressing for the practice to be able to be compliant,for example the need for a designated member of staffto be trained to be able to undertake water tests. Thepractice was unable to verify that the recommendationshad been addressed.

• All electrical equipment was checked to ensure it wassafe to use and clinical equipment was checked toensure it was working properly. Defibrillators and fridgethermometers in the dispensary had not been includedin the calibration schedule. The practice informed usthey would address this immediately.

Medicines management

• The practice was signed up to the Dispensing ServicesQuality Scheme (DSQS) to help ensure dispensingprocesses were suitable and the quality of the servicewas maintained. The practice had carried out adispensing review of patients (DRUMS) on 10% of theirpatients to ensure that medicines are being used safelyand correctly. Dispensing staff were appropriatelyqualified, were provided some on-going trainingopportunities and had their competency annuallyreviewed.

• The practice had written procedures in place for theproduction of prescriptions and dispensing ofmedicines that were regularly reviewed. There were avariety of ways available to patients to order their repeatprescriptions and there were arrangements in place toprovide medicines compliance aids. We were told thatmedicines were transported to the branch surgery atFenstanton and stored securely there. These medicinesincluded prescriptions for collection by patientsregistered with the practice in Fenstanton. We saw noevidence that this arrangement had been risk assessedto ensure the safety and security of the medicines, norwas there a protocol to cover this process. Prescriptionswere reviewed and signed by GPs before they were givento patients, however, some repeat prescriptions andemergency prescription requests were dispensed topatients without being signed by the GP. Dispensarystaff told us they always sought verbal approval whenthis occurred.

Are services safe?



• Blank prescription forms were recorded and trackedthrough the practice but those used in printers were notalways secured appropriately.

• Records showed medicine refrigerator temperaturechecks were carried out which ensured medicinesrequiring refrigeration were stored at appropriatetemperatures. There was a policy for ensuring thatmedicines were kept at the required temperatures anddescribed the action to take in the event of a potentialfailure. The practice staff followed the policy. We notedthat thermometers used to record room and refrigeratortemperatures had not been calibrated to ensure theiraccuracy.

• Arrangements were in place to check medicines storedwithin the dispensary areas were within their expiry dateand suitable for use.

• We observed that the practice had a number of PatientsGroup Directions (PGDs) in place and that these were inline with national guidelines and were being maintainedand reviewed to a high standard by the lead practicenurse and that all PGDs had been signed by the lead GP.

• The practice held stocks of controlled drugs (medicinesthat require extra checks and special storagearrangements because of their potential for misuse) andhad in place standard procedures that set out how theywere managed. These were being followed by thedispensary staff. For example, controlled drugs werestored in an appropriate cupboard and access to themwas restricted and the keys held securely. However, wenoted that security arrangements for access to thedispensary after working hours were unsatisfactory inthat non-clinical staff including cleaners could enter thedispensary without being supervised by senior practicestaff. We were told by the practice manager that securitysystems were being reviewed following two recent theftsfrom the dispensary and that the police had beeninformed and they were advising the practice onchanges that need to be made to increase security.

• There was a system in place for the management of highrisk medicines, which included an audit to ensure thepractice operated in line with national guidance. Wereviewed methotrexate (used in the treatment ofrheumatoid arthritis or cancer) and lithium (used to

treat and prevent episodes of mania) records and sawthese were appropriately highlighted on the practice’ssystem and that patients on these medications hadundergone timely reviews and checks such as bloodtests.

• Expired and unwanted medicines (including controlleddrugs) were disposed of in line with waste regulationsand protocols within the dispensary.

• We saw a positive culture in the dispensary for reportingand learning from medicine incidents and errors.Dispensing errors were logged, reviewed to monitortrends and appropriate actions were taken to preventsimilar errors occurring but these were not shared withthe rest of practice.

Arrangements to deal with emergencies and majorincidents

There was an instant messaging system on the computersin all the consultation and treatment rooms which alertedstaff to any emergency.

All staff received annual basic life support training andthere were emergency medicines available at bothlocations. Emergency medicines were easily accessible tostaff near and all staff knew of their location. All themedicines we checked were in date and fit for use except atthe branch location where we noticed that the atropine (adrug used in the treatment of bradycardia) had passed itsexpiry date of March 2016. Although it was clearly noted onthe packaging that it was not to be used it had not yet beenreplaced. The practice informed us they could obtain thisfrom the dispensary at the main location if required butsaid they would replace the atropine after we highlightedthis.

The practice had a defibrillator available on the premises,along with oxygen with adult and children’s masks. Therewas a first aid kit available.

The practice had a very comprehensive business continuityplan in place for major incidents such as power failure orbuilding damage. The plan included emergency contactnumbers for staff.

Are services safe?



Our findingsEffective needs assessment

The practice assessed patients’ needs and delivered care inline with relevant and current evidence based guidanceand standards, including National Institute for Health andCare Excellence (NICE) best practice guidelines. Thepractice had systems in place to keep all clinical staff up todate. Staff had access to guidelines from NICE and usedthis information to deliver care and treatment that metpeople’s needs.

Management, monitoring and improving outcomes forpeople

The practice participated in the Quality and OutcomesFramework (QOF - is a voluntary incentive scheme for GPpractices in the UK. The scheme financially rewardspractices for managing some of the most commonlong-term conditions e.g. diabetes and implementingpreventative measures. The results are publishedannually). The practice used the information collected forthe QOF and performance against national screeningprogrammes to monitor outcomes for patients. In 2014/2015 the practice achieved 90.8% of the total number ofpoints available, which was below the national average of94.7% and the local average of 94.2%. The practicereported 3.4% exception reporting which was 7.1% belowlocal, and 5.8% below national average (exceptionreporting is the removal of patients from QOF calculationswhere, for example, the patients are unable to attend areview meeting or certain medicines cannot be prescribedbecause of side effects):

• Performance for asthma, atrial fibrillation, cancer,chronic obstructive pulmonary disease, epilepsy, heartfailure, hypertension, learning disability, mental health,palliative care, peripheral arterial disease, palliative careand rheumatoid arthritis, were better or the same incomparison to the CCG and national averages with thepractice achieving 100% across each indicator. Exceptfor chronic obstructive pulmonary disease (COPD) andheart failure, the exception reporting rates for theseindicators were lower than, or in line with, the CCG andnational averages.▪ Exception reporting for 'the percentage of patients

with COPD (diagnosed on or after 1 April 2011) inwhom the diagnosis has been confirmed by post

bronchodilator spirometry between 3 months beforeand 12 months after entering on to the register' was36.4% compared to the CCG average of 13.3% andthe national average of 9.8%.

▪ Exception reporting for 'the percentage of patientswith a diagnosis of heart failure (diagnosed on orafter 1 April 2006) which had been confirmed by anechocardiogram or by specialist assessment 3months before or 12 months after entering on to theregister' was 9.1% compared to the CCG average of6.1% and the national average of 4.6%.

• Performance for cancer related indicators was below theCCG and national average. With the practice achieving77.3%, this was 21.3% below the CCG average and 20.6%below the national average. In response to the low scorewe reviewed the practice’s performance for 2015/2106’sQOF and noted that the practice had achieved all thepoints available. This data was not yet officially verifiedand was not yet publicly available at the time of thisinspection.

• Performance for chronic kidney disease relatedindicators was higher compared to the CCG and nationalaverage. With the practice achieving 99.3%, this was7.5% above the CCG average and 4.6% above thenational average.

• Performance for dementia related indicators was lowercompared to the CCG and national average. With thepractice achieving 80.2%, this was 14.8% below the CCGaverage and 14.3% below the national average. Inresponse to the low score we reviewed the practice’sperformance for 2015/2106’s QOF and noted that thepractice had achieved all the points available. This datawas not yet officially verified and was not yet publiclyavailable at the time of this inspection.

• Performance for depression related indicators was lowercompared to the CCG and national average. With thepractice achieving 0%, this was 90.6% below the CCGaverage and 92.3% below the national average. Weasked the practice about their performance in this areaand were informed that this related to eight patientsand was due to incorrect coding on the practice’scomputer system. In response to the low score wereviewed the practice’s performance for 2015/2106’sQOF and noted that the practice had achieved all thepoints available. This data was not yet officially verifiedand was not yet publicly available at the time of thisinspection.

Are services effective?(for example, treatment is effective)



• Performance for diabetes related indicators was lowercompared to the CCG and national average. With thepractice achieving 87.6%, this was 1.9% below the CCGaverage and 1.6% below the national average.

• Performance for osteoporosis: secondary prevention offragility fractures related indicators was lower comparedto the CCG and national average. With the practiceachieving 66.7%, this was 15.4% below the CCG averageand 14.7% below the national average. In response tothe low score we reviewed the practice’s performancefor 2015/2106’s QOF and noted that the practice hadachieved all the points available. This data was not yetofficially verified and was not yet publicly available atthe time of this inspection.

• Performance for peripheral arterial disease, secondaryprevention of coronary heart disease and stroke andtransient ischaemic attack related indicators were lowercompared to the CCG and national average.

• In response to some of the below average performanceson the above indicators we reviewed the 2015/2016 QOFdata for the practice. This data had not yet beenvalidated by the Health and Social Care InformationCentre and was not yet publicly available at the time ofthis inspection but indicated that the practice hadachieved 532.2 points out of a potential 545. This was animprovement from 2014/2015.

The lead GP explained that clinical audits were carried outto demonstrate quality improvement and relevant staffwere involved to improve care and treatment and people’soutcomes. We discussed a number of clinical audits withthe lead GP on the day of the inspection but we were notprovided with written evidence until after the inspection.The audits included an audit on dementia patients beingprescribed anti-psychotic medicines. The first audit hadindicated three out of 17 patients were on this type ofmedication. Following actions from the practice, a secondcycle of the audit indicated that nil out 17 patients were onanti-psychotic medicines.

Effective staffing

We could not consistently be assured that staff had theskills, knowledge and experience to deliver effective careand treatment.

• The practice had an induction program for newlyappointed members of staff that covered topics such ashealth and safety, confidentiality and organisation rules.

• Staff had access to, and made use of, e-learning trainingmodules, in-house and external training. Howeverseveral members of staff told us they did not receiveallocated time or resources to undertake mandatorytraining and undertook this in their own time. Recordsindicated that there were gaps in various topicsincluding safeguarding adults, equality and diversity,manual handling, information governance, health andsafety and infection control amongst others for variousstaff. We saw records that indicated all staff had receivedup to date basic life support training.

• We saw evidence that some staff had received supportby means of one-to-one meetings, inductions, coachingand mentoring, clinical supervision and facilitation andsupport for the revalidation of GPs but staff stated thissupport was not always timely or in-depth. Evidence wereviewed indicated five staff members' appraisals wereoverdue.

Coordinating patient care and information sharing

The information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the practice’s patient record systemand their intranet system. This included care and riskassessments, care plans, medical records and test results.

Staff worked together and with other health and social careservices to understand and meet the range and complexityof people’s needs and to assess and plan on-going careand treatment. This included when people moved betweenservices, including when they were referred, or after theywere discharged from hospital.

We saw evidence that multi-disciplinary team meetingstook place on a monthly basis and that care plans werereviewed and updated.

Information such as NHS patient information leaflets wereavailable in the patient waiting room.

Consent to care and treatment

Patients’ consent to care and treatment was always soughtin line with legislation and guidance. Staff understood therelevant consent and decision-making requirements oflegislation and guidance, including the Mental Capacity Act2005. When providing care and treatment for children andyoung people, assessments of their capacity to consentwere also carried out in line with relevant guidance. Where




a patient’s mental capacity to consent to care or treatmentwas unclear the GP or nurse assessed the patient’s capacityand, where appropriate, recorded the outcome of theassessment.

Supporting patients to live healthier lives

Patients who might be in need of extra support wereidentified by the practice. These included patients in thelast 12 months of their lives, carers and those at risk ofdeveloping a long-term condition. Patients were thensignposted to the relevant service.

• The practice had a comprehensive cervical screeningprogramme. The practice’s percentage of patientsreceiving the intervention according to 2014-2015 datawas 80.0%, which was in line with the England averageof 81.8%. Patients who had not attended for a screeningappointment were followed up with letters and via thetelephone.

• Childhood immunisation rates for the vaccinationsgiven to under twos ranged from 82.1% to 100%compared to the local average of 52.1% to 95.7%, andfor five year olds from 84.6% to 100% compared to thelocal average of 87.7% to 95.4%.




Our findingsRespect, dignity, compassion and empathy

We observed that members of staff were courteous andhelpful to patients, and treated them with dignity andrespect. We received mixed views from patients about howthey were treated with some indicating the standard ofcaring they received was good. One patient said that theyhad not been satisfied with the service provided by oneparticular GP who, we were told, could be rude anddismissive to them and that they would not want to beseen by that GP again.

We discussed this with members of staff including thepractice manager who told us they were aware that not allpatients were happy with the service they received from theGP. The practice manager told us this would be discussedwith the GP.

Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments. We noted that consultationand treatment room doors were closed duringconsultations but that conversations taking place in theserooms at the main location could potentially be overheard.We saw that at least one of the doors to the consultationrooms did not provide sufficient confidentiality.

The front desk did not provide sufficient confidentialitywith limited queuing space and the waiting area beingwithin earshot; phone calls were being answered at thefront desk and could be overheard. The practice wereaware of this but explained little could be changed as thebuilding was listed and layout changes were not possible.Receptionists we spoke with were conscious of requestingpatients to wait at a safe distance from the desk but thiscould prove difficult due to the size of the area.

As part of our inspection we asked for CQC comment cardsto be completed by patients prior to our inspection; wecollected 14 completed cards. Nine of the comment cardswe received contained positive and complimentary patientviews about the service, one card contained negativecomments regarding care and referrals received, two cardscontained comments that a high staff turnover was evidentbut were positive about the care received, one cardcontained negative comments about one GP who they felt

could be uncaring but also included positive commentsabout another GP. One card contained comments that theservice was good but raised concerns that it was difficult tosee a GP of choice.

We spoke with five patients who provided varyingresponses in being able to get an appointment with onestating it could be difficult and three stating it was easy.They told us they felt the practice offered a good serviceand that staff were polite, helpful, caring and treated themwith dignity and respect, however one patient commentedthat a GP could be perceived as being rude.

Results from the National GP Patient Survey published inJanuary 2016 were above or in line with CCG and nationalaverages for patient satisfaction scores in most areas. Forexample:

• 89% said the GP was good at listening to themcompared to the CCG average of 89% and nationalaverage of 89%.

• 88% said the GP gave them enough time compared tothe CCG average of 87% and national average of 87%.

• 99% said they had confidence and trust in the last GPthey saw compared to the CCG average of 96% andnational average of 95%.

• 84% said the last GP they spoke to was good at treatingthem with care and concern compared to the CCGaverage of 85% and national average of 85%.

• 98% said the last nurse they spoke to was good attreating them with care and concern compared to theCCG average of 91% and national average of 91%.

• 99% said the nurse gave them enough time comparedto the CCG average of 93% and national average of 92%.

• 92% patients said they found the receptionists at thepractice helpful compared to the CCG average of 88%and national average of 87%.

Care planning and involvement in decisions aboutcare and treatment

Patients told us that they felt involved in decision makingabout the care and treatment they received. They also toldus they felt listened to and supported by staff and hadsufficient time during consultations to make an informeddecision about the choice of treatment available to them.

Results from the National GP Patient Survey published inJanuary 2016 showed patients responded positively and

Are services caring?

Good –––


generally above average to questions about theirinvolvement in planning and making decisions about theircare and treatment. Results were above local and nationalaverages. For example:

• 88% said the last GP they saw was good at explainingtests and treatments compared to the CCG average of87% and national average of 86%.

• 85% said the last GP they saw was good at involvingthem in decisions about their care compared to the CCGaverage of 82% and national average of 82%.

• 95% said the last nurse they saw was good at explainingtests and treatments compared to the CCG average of90% and national average of 90%.

• 93% said the last nurse they saw was good at involvingthem in decisions about their care compared to the CCGaverage of 85% and national average of 85%.

Staff told us that translation services were available forpatients who did not have English as a first language.

Patient and carer support to cope emotionally withcare and treatment

Information in the patient waiting rooms told patients howto access a number of support groups and organisations,there was a designated carer’s information board. Thepractice’s computer system alerted GPs if a patient wasalso a carer. There was a practice register of all people whowere carers, 37 patients (approximately 1%) on the practicelist had been identified as carers and were beingsupported, for example, by offering them health checksand referral for organisations such as social services forsupport. 42 patients were identified as being cared for. Thepractice manager informed us that the practice had hosteda Carer’s Trust event approximately one year prior to ourinspection.

Staff told us that if families had suffered bereavement, theirusual GP contacted them. This call was either followed by apatient consultation at a flexible time and location to meetthe family’s needs and/or by giving them advice on how tofind a support service.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

The practice worked with NHS England and the ClinicalCommissioning Group (CCG) to plan services and toimprove outcomes for patients in the area. The practiceheld information about the prevalence of specific diseases.This information was reflected in the services providedthrough screening programmes and vaccinationprogrammes.

Services were planned and delivered to take into accountthe needs of different patient groups and to help ensureflexibility, choice and continuity of care:

• Online appointment booking and prescription orderingwas available for patients.

• Home visits were available for older patients or patientswho would benefit from these.

• Urgent access appointments were available for childrenand those with serious medical conditions.

• There were disabled facilities, a hearing loop andtranslation services available.

• All clinical rooms had space for wheelchairs and prams/pushchairs to manoeuvre. Hallways were somewhatnarrow in places but due to building restrictions thepractice were unable to improve this Staff were aware ofpatients who had limited access and offered supportwhen required.

• GPs visited a local care home at least once a week.When we spoke to the care home they stated that thecare they received was of a good standard andresponsive to the residents’ needs. They specificallyhighlighted that the care given to palliative patients wasof a good standard.

• The practice hosted external hearing help services toallow this treatment to be delivered to patients closer totheir home and to eradicate the need to travel to thehospital for this. The practice provided facilities free ofcharge for these services.

• The lead GP provided sports medicine andmusculo-skeletal clinics.

• Flexible appointments were available as well as setclinic times.

• The practice provided clinics for patients with long termconditions, which were nurse led.

• Midwives provided regular clinics from the practice’spremises.

Access to the service

The practice’s opening times at the time of the inspectionwere 08:00 to 18.00 Monday to Friday. Extended hoursappointments were offered on Tuesday and Thursdaymorning between 07:00 and 08:00 but were for nurseappointments only.During out-of-hours GP services wereprovided by Urgent Care Cambridge.

Results from the National GP Patient Survey published inJanuary 2016 showed that patients’ satisfaction with howthey could access care and treatment was in most caseshigher than local and national averages:

• 69% of patients were satisfied with the practice’sopening hours compared to the CCG average of 75%and national average of 75%.

• 96% patients said they could get through easily to thesurgery by phone compared to the CCG average of 75%and national average of 73%.

• 90% patients described their experience of making anappointment as good compared to the CCG average of77% and national average of 73%.

• 76% patients said they usually waited 15 minutes or lessafter their appointment time compared to the CCGaverage of 64% and national average of 65%.

Listening and learning from concerns and complaints

The practice had an effective system in place for handlingcomplaints, compliments and concerns. Its complaintspolicy and procedures were in line with recognisedguidance and contractual obligations for GPs in England.There was a designated responsible person who handledall complaints in the practice. Complaints were notdiscussed at practice and clinical meetings and we saw noevidence that learning from complaints had taken place.

Information about how to make a complaint was availableat reception and there was reference to this being made onthe website. Not all patients we spoke with were awarehow to raise a complaint but those who didn’t stated theywouldn’t hesitate to ask staff. Reception staff showed agood understanding of the complaints’ procedure.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Our findingsVision and strategy

The practice had a vision to provide their patients with“personal health care of the highest quality and to strive toimprove the health status of the practice population” withaims and objectives including “commitment to ourpatients’ needs” and “ensuring effective management andgovernance systems” amongst others.

We found that, at the time of inspection, correlationbetween the practice’s aims and objectives and ourfindings was inconsistent as governance systems were notrobust and management was not always effective. Thepractice worked with the CCG and other local practicestowards development of general practice in the area.

Governance arrangements

There were structures and procedures in place but thesewere not robust enough to ensure the practice had aneffective governance framework to support the delivery ofthe strategy and good quality care.

• Communication across the practice was structuredaround key scheduled meetings. There were regularbusiness meetings and staff told us that nurses’meetings took place on an ad-hoc basis, which workedwell for the nursing team. Staff meetings involving alladministrative staff took place monthly. We found thatthe quality of record keeping within the practice wasinconsistent, with minutes and records required byregulation for the safety of patients being detailed,maintained, up to date and accurate for some meetingsbut not for others. For example, business meetingsinvolving the lead GP and the practice manager werenot minuted, which resulted in the practice not havingrobust evidence on the decision making processes andrationales. Clinical meetings were recorded and we sawevidence of this.

• Although the practice had procured an external healthand safety risk assessment which had produceddetailed findings there were no robust arrangements foraddressing the outcomes and implementing mitigatingactions. Some actions had been addressed whereothers had not been dealt with.

• There was a clear staffing structure and planning andstaff were aware of their own roles and responsibilities.Some staff were multi-skilled and were able to covereach other’s roles within their teams during leave orsickness.

• The practice used methods of communication thatinvolved the whole staff team and other healthcareprofessionals to disseminate best practice guidelinesand other information. These methods did not alwaysprovide assurance that all staff had received and notedimportant information. For example, the practice’spolicies were available on the practice’s computersystem and in the staff room but we saw that not all staffhad signed for confirmation to acknowledge they hadread them.

• GPs were supported to address their professionaldevelopment needs for revalidation.

• Learning from incidents and complaints was notconsistently shared with staff unless they were directlyinvolved, which limited the extent to which the practicecould learn from errors. We saw evidence that thepractice manager updated staff on practice matters on aregular basis.

• The practice did not have a robust system in place forreporting and recording significant events. We foundthat reporting was scarce with only three incidentsreported in the previous 12 months. We saw evidence of,and were verbally told by staff about, incidents that hadoccurred in the practice over the previous few monthswhich had not been recorded as significant event butshould have been.

• A review of action points coming out of staff meetings,complaints and significant event recording did notprovide assurance that information was used effectivelyto trigger improvement. For example, the practice wasunable to verify that the recommendations from thelegionella risk assessment in 2013 had been addressed.

• The practice had a number of policies and proceduresto govern activity but we found that these had a reviewdate of 2014 and had not been reviewed. The practiceinformed us they would immediately revise all theirpolicies.

• The lead GP told us they had undertaken clinical auditswhich were used to monitor quality and systems toidentify where action should be taken and driveimprovements. We saw evidence that supported theGPs' revalidation process.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



Leadership and culture

There was scope for the practice leadership to beimproved. Staff we spoke with confirmed that the lead GPwas not always visible in the practice and staff told us thatthey were not always approachable nor took the time tolisten to all members of staff. Staff confirmed that they feltclinically supported by the lead GP. Staff also told us theyfelt the practice manager was visible in the practice andsupported staff when needed. They explained that if therewere any non-clinical concerns they would approach thepractice manager.

One of the nurses confirmed that the lead GP supportedthem in undertaking a prescribing course which was due tostart in September.

The practice had undergone a high turnover of staff overthe previous year and made use of three regular locum GPsin addition to the full time lead GP and part time salariedGP. The lead GP explained that the practice hadexperienced recruitment challenges and had beenexploring the option to extend to a partnership. We weretold by management and staff that the practice hadorganised social events in the last year for all staff toattend.

Seeking and acting on feedback from patients, thepublic and staff

The practice encouraged and valued feedback frompatients by proactively engaging patients in the delivery ofthe service. There was an active patient participation group(PPG) which met formally on a regular basis, approximatelyevery two months. These meetings were attended by thepractice manager at all times and by a GP where possible.We spoke with one representative of the PPG which had sixto seven active members at the time of our inspection.They commented that suggestions from the PPG werewelcomed by the practice and that they had beenconsulted on their patients’ viewpoint on a regular basis.For example, feedback on the waiting room had resulted ina change of chairs and information available.

Staff told us that various regular team meetings were heldbut that openness in the practice required improvement.They did not feel they always had the opportunity to raiseissues at team meetings or in person and were notconfident in doing so. Non-clinical staff said they feltrespected and valued by the practice manager but notalways by the lead GP. Some members of clinical staffconfirmed they felt clinically supported by the GPs but notalways personally.

We saw in minutes from meetings that a variety of topicswere openly discussed with staff but that GPs did notalways attend these meetings.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

(1) Care and treatment must be provided in a safe wayfor service users.(2) Without limiting paragraph (1), thethings which a registered person must do to comply withthat paragraph include-

(b) doing all that is reasonably practicable to mitigateany such risks

(g) the proper and safe management of medicines.

(h) assessing the risk of, and preventing, detecting andcontrolling the spread of, infections, including those thatare health care related.

Effective procedures to comply with relevant PatientSafety Alerts issued from the Medicines and Healthcareproducts Agency (MHRA) and the Central Alerting System(CAS) were not in place.

Prescriptions were not always signed by GPs before theywere given to the patient.

Effective infection control procedures were not in place.



Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

(1) Systems or processes must be established andoperated effectively to ensure compliance with therequirements in this Part

(2) Without limiting paragraph (1), such systems orprocesses must enable the registered person, inparticular, to—

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


(a) assess, monitor and improve the quality and safety ofthe services provided in the carrying on of the regulatedactivity (including the quality of the experience of serviceusers in receiving those services);

(b) assess, monitor and mitigate the risks relating to thehealth, safety and welfare of service users and otherswho may be at risk which arise from the carrying on ofthe regulated activity;

(d) maintain securely such other records as arenecessary to be kept in relation to—

(i) persons employed in the carrying on of the regulatedactivity, and

(ii) the management of the regulated activity.

Mandatory training was not up to date for all staff,including training for safeguarding.

Policies, procedures and guidance available in thepractice was not always up to date. This hindered staff tooperate in accordance with up to date procedures.



Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

(1) Persons employed for the purposes of carrying on aregulated activity must-

(a) be of good character;

(b) have the qualifications, competence, skills andexperience which are necessary for the work to beperformed by them.

(2) Recruitment procedures must be established andoperated effectively to ensure that persons employedmeet the conditions in – (a) paragraph (1)

(3) The following information must be available inrelation to each such person employed-

(a) the information specified in Schedule 3, and

(b) such other information as is required under anyenactment to be kept by the registered person in relationto such persons employed.

Regulation


Requirement notices


Not all staff caring for patients and/or undertakingchaperone duties had received a Disclosure and BarringService check (DBS).


Surgical procedures


Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

(1) All premises and equipment used by the serviceprovider must be-

(b) secure,

Security arrangements must make sure that people aresafe while receiving care, including

Providing appropriate access to and exit from protectedor controlled areas.

Using the appropriate level of security needed in relationto the services being delivered.

Appropriate dispensary access and security systemswere not in place.

Regulation


Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.



Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

(1) Systems or processes must be established andoperated effectively to ensure compliance with therequirements in this Part

(2) Without limiting paragraph (1), such systems orprocesses must enable the registered person, inparticular, to—

(a) assess, monitor and improve the quality and safety ofthe services provided in the carrying on of the regulatedactivity (including the quality of the experience of serviceusers in receiving those services);

(b) assess, monitor and mitigate the risks relating to thehealth, safety and welfare of service users and otherswho may be at risk which arise from the carrying on ofthe regulated activity;

(d) maintain securely such other records as arenecessary to be kept in relation to—

(i) persons employed in the carrying on of the regulatedactivity, and

(ii) the management of the regulated activity.

Regulation


Enforcement actions


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