Mayford House Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jackson and Partners on 10 May 2016. The overall rating for the practice was requires improvement. We undertook a further announced focused inspection on 24 January 2017. The overall rating for the practice remained at requires improvement. The full comprehensive reports on the May 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Dr Jackson and Partners on our website at www.cqc.org.uk.

This inspection was an announced comprehensive carried out on 16 November 2017 to check whether the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This practice is rated as Good overall. (Previous inspections May 2016 and January 2017 – Requires improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• 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.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

Consideration should be given to whether specific complaints need to be recorded as significant events.

Review the systems in place for reviewing changes introduced overtime for significant events and complaints to assess whether the changes have been effective and embedded into practice.

Consider the arrangements in place to support non--clinical staff to be aware of patients at risk of sepsis.

Review the process for regular monitoring of prescriptions that have not been collected.

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 Dr Jackson and Partners (previously known as Dr Walters and Partners and also known as Mayford House Surgery) on 24 January 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the 10 May 2016 inspection can be found by selecting the link below on our website at www.cqc.org.uk. http://www.cqc.org.uk/location/1-577985237

This inspection was an announced focused inspection carried out on 24 January 2017. The inspection was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 10 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as requires improvement.

Our key findings were as follows:

• The system and processes in place for reporting, recording and reviewing significant events had improved in some but not all areas. Despite this we identified that significant events were still not always being recorded and actioned and in some cases there was insufficient information recorded to allow adequate investigation.

• There were still gaps in the safeguarding children and adults training completed by staff.

• The practice had addressed some of the issues relating to medicines management.

• All staff had a Disclosure and Barring Service (DBS) check in place. Despite this there remained some concern in respect of the management of the recruitment process.

• The practice had made some improvement in the management of health and safety. We saw evidence to show that recommendations by external agencies had been acted on. However, there remained gaps in staff training in this area. For example fire safety, health and safety and cardio pulmonary resuscitation (CPR).

• The practice had in the last two weeks put a system in place to ensure patients with a learning disability were recalled to the practice for a review.

• The practice could not demonstrate how they ensured role-specific training and updating for relevant staff. Whilst some recent steps had been taken by the practice management to review the systems for managing training there remained significant gaps in the completion of mandatory training. There was a lack of understanding as to the frequency of the requirements of such training.

• Since our last inspection there had been significant changes in the partnership arrangements. There was a new partnership arrangement and a new CQC registered manager in place. There was a clear commitment from the new partnership to deliver improvements.

• Evidence showed the partners had started to take steps towards improving the governance arrangements at the practice. Whilst there was clear evidence of improvement there were still areas that required improvement or further improvement.

Importantly, the provider must:

• Ensure that all significant events are reported, reviewed, investigated and that measures are in place to see whether the changes introduced have been effective and embedded into practice.

• Ensure that all vaccines are stored, managed and disposed of properly so that immunisations are carried out safely and efficiently in line with Public Health England guidance.

• Review the effectiveness of the management of training so that persons employed by the practice receive appropriate training as is necessary to enable them to carry out the duties they are employed to perform.

• Review the effectiveness of the governance systems and processes in place to enable the practice to assess, monitor and mitigate risks to the health, safety and welfare of their patients and staff.

At our previous inspection on 10 May 2016, we rated the practice as inadequate for providing safe services and requiring improvement for providing effective and well led services. Whilst improvement had been made at this inspection and there was evidence of an improvement pathway we still found issues that required improvement or further improvement. Consequently, the practice has been rated as requires improvement for safe which is reflective of some of the improvement we saw; requires improvement for effective as little improvement had been made in respect of training, and well led rated as requires improvement. It should be noted that there has been improvement in this area with the new partnership arrangement and some of the new governance arrangements and engagement with staff. However there are still a wide range of areas that need improvement. Consequently the rating for well led remains as requires improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice