Elm Tree Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Elm Tree Surgery on 20 October 2015.

This was the first inspection using the CQC comprehensive inspection programme. Overall the practice is rated as inadequate. Elm Tree Surgery was committed to delivery of caring and responsive services for its patients. However, the practice did not demonstrate a culture of managing safety and assessing and managing risk.

We found the practice good for the delivery of effective and caring services and outstanding for provision of responsive services. However, the practice was found to be inadequate for provision of safe and well led services and these ratings affected all the population groups.

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

• The practice performance in achieving high rates of cervical cytology screening and childhood immunisations was as good as, or better than, other practices in the locality. This was achieved within the context of a high turnover of female patients, a birth rate double the national average and the need to harmonise immunisation regimes with those of other countries.

• Patients were able to access same day appointments and routine appointments were available within two days. Patient feedback showed they could see the GP of their choice promptly to maintain continuity of care.
• The practice recognised the needs of the rural population. For example dispensed medicines could be collected from two local post offices and flu clinics were held in village halls.
• Although there was evidence of effective clinical leadership that were engaged in leading and ensuring the delivery of care we also found that this was not supported by the necessary management infrastructure and leadership.
• 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.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Data showed patient outcomes were above average for the locality and above national averages.

However,

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, learning from such events was communicated inconsistently.
• Staff were able to recognise signs of abuse but were unclear of their responsibilities to report suspected abuse to statutory authorities.
• Procedures to keep medicines safe were not operated effectively.
• Governance arrangements in the practice were weak and improvements were required in relation to the management and assessment of risk. For example, Actions to reduce the risk of cross infection had been identified via audit but had not been taken in a timely manner. The practice did not demonstrate a culture of managing safety and assessing risk.
• Staff of the practice reported that management did not routinely seek and act on staff feedback.
• We identified poor levels of collaboration and cooperation between specific team members and some staff reported a level of conflict with inappropriate behaviour directed towards them.

• Staff were appropriately trained to carry out their duties but had not been involved in identifying their training needs.

We saw areas of outstanding practice:

• Patients were able to access appointments and services in a way that suited them. The practice offered prompt access to appointments with the GP of patient choice. Feedback on access to services was consistently better that the locality and national averages and a range of services were offered that recognised the needs of the practice population.

• The practice offered an extended minor injuries service to enable patients to access this locally and avoid a trip to the hospital A&E. The last data available showed the practice had 180 patients attend A&E in one year compared to the local average of 235 and national average of 388

• The practice had researched childhood immunisation regimes in other countries. This resulted in aligning immunisations with overseas practice and resulted in a high rate of take up of childhood immunisations among the families of patients from other countries.

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

Importantly, the provider must:

• Improve the management of medicines to ensure they are held safely and update processes used to reduce the risks associated with medicines.
• Ensure patient records are maintained safely with staff having secure personal access to the records system.
• Introduce an appropriate system that is accessible to all staff to record and report back on significant events.
• Ensure all relevant risk assessments are undertaken and any action arising from such assessments is undertaken.
• Ensure staff training in safeguarding includes reporting a concern to the relevant authorities. Update the local safeguarding contact details within the practices safeguarding protocols.
• Ensure appraisals take place on a regular basis and that staff receive support and supervision relevant to their roles.
• Ensure risks identified from the 2014 control of infection audit are addressed and undertake annual control of infection audits.
• Develop and implement cleaning schedules for all areas of the practice.

In addition the provider should:

• Promote the availability of the chaperone service.
• Ensure all staff are aware of the translation service and how to access this for patients.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice