The Billesdon Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Billesdon Surgery on 17 September 2015. Overall the practice is rated as inadequate.

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

• The system for reporting, investigation and dissemination of learning from significant events was inconsistent and disjointed so safety was not always improved.
• Data showed patient outcomes were in line with the national average. Although some audits had been started, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• Systems and processes within the dispensary were not robust.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day due to the practice’s daily open surgery.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• We found there were limited means of accessing information about how to complain.

• The practice had a number of policies and procedures to govern activity, but some were over five years old and there was no evidence they had been reviewed since.

• The practice had limited means of encouraging feedback from patients with a view to engaging patients in the delivery of the service and had not always acted on issues raised by staff.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, the system in place for monitoring and reviewing patients on methotrexate was not adequate.

The areas where the provider must make improvements are:

• Ensure there is a clear and consistent system for dealing with significant events and that staff are supported to raise incidents.

• Ensure the complaints system is accessible.

• Ensure there are formal governance arrangements in place and staff are aware how these operate, including having appropriate policies and guidance in place.
• Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.

• Ensure there are effective systems in place for monitoring patients and the quality of care, including appropriate care plans being in place, the ‘hypertension improvement plan’and ‘methotrexate prescribing protocol’ being implemented and adhered to and robust clinical audits being undertaken in the practice, including completed clinical audit or quality improvement cycles.

• Ensure all staff are up to date with mandatory training.

• Ensure appropriate fire safety arrangements in place, including regular fire drills and fire alarm testing and an up to date fire risk assessment in place.

• Ensure there is a robust system in place for the management of emergency equipment and medicines.

• Ensure all staff receive annual appraisals.
• Ensure systems and processes in the dispensary are robust, including adequate leadership and that competencies of dispensary staff are checked appropriately.
• Ensure appropriate risk assessments are in place, for example,legionella and staff working alone at branch surgery.
• Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, including actions from infection control audits being recorded and implemented.
• Ensure a statement of purpose is in place and submitted to the Care Quality Commision.

In addition the provider should:

• Ensure a comprehensive business continuity plan is in place.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have not 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. I have also served a notice on the provider placing conditions on their registration, which they must comply with.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice