Archived: Melbourne House Surgery

This practice is rated as requires improvement overall. (Previous rating October 2017 – Requires Improvement and August 2015 – Good)

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• The security of prescription pads was ineffective.
• The practice did not have an effective system for the recording of significant events and learning from these to make improvements was not clearly demonstrated.
• Areas identified as in need of action from the infection control audit were not followed up.
• Fridge temperatures were not clearly monitored, and the practice had no cold chain policy in place.
• Locum GP checks including immunity status and training checks were not carried out.
• There were no risk assessments in place for the security of the premises and also for the storage of hazardous substances.

We rated the practice as requires improvement for effective because:

• The practices clinical outcomes indicators for 2017/2018 for people experiencing poor mental health and for people with long term conditions, in particular those with diabetes was below local and national averages. Although the unverified data from 2018 shows an increase we found no action plan to indicate these figures had been fully addressed.

We rated the practice as requires improvement for well-led because:

• While the practice had made some improvements since our inspection in October 2017 it had not completely addressed the requirement notice in relation to the infection control audit. At this inspection we also identified additional concerns that put patients at risk.
• The practice lacked a system for quality assurance including clinical audit.
• We also found there was a lack of governance and performance was not being monitored effectively

We rated the population group people experiencing poor mental health as requires improvement because:

• The practice’s clinical outcome indicators for 2017/2018 were below the local and national average for people experiencing poor mental health. The unverified data from this year showed an increase however it remained lower then local and national averages. As this population group was rated as requires improvement for providing effective services, this means that the overall rating for this population group is requires improvement.

We rated the population group people long term conditions as requires improvement because:

• The practice’s clinical outcome indicators for 2017/2018 were below the local and national average for people with long term conditions, in particular for diabetes. The unverified data from this year showed an increase however we found no action plan to indicate these figures had been fully addressed. As this population group was rated as requires improvement for providing effective services, this means that the overall rating for this population group is requires improvement.

We rated the practice as good for providing caring & responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patient’s needs. Patients could access care and treatment in a timely way.
• Patients received effective care and treatment that met their needs.

During our inspection in October 2017 we identified some breaches of the regulations and issued the practice with a requirement notice for improvement. The areas where the provider must make improvements were:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example,
• Implement a system to evidence the action taken in response to national safety alerts
• Implement an effective system to identify staff learning needs including the completion of essential training and regular staff appraisals.
• Undertake infection prevention and control audits.
• Ensure documentary evidence of appropriate recruitment checks for staff members.

At this inspection we found that some areas had been satisfactory addressed however there were still some areas that remain unresolved and therefore the requires improvement rating remains.

During our inspection in October 2017 we also identified other areas where they should improve. The areas where the provider should make improvements were:

• Continue to improve patient satisfaction data in relation to patient waiting times.
• Ensure an appropriate system is in place for the safe use of prescription pads and the management of uncollected prescriptions.
• Implement a system to ensure patient care plans are reviewed and monitored on a regular basis.
• Implement systems to identify and support carers.
• Review practice policies on a periodic basis.
• Maintain a copy of the business continuity plan off the premises.
• Record and analyse verbal complaints and manage all complaints in accordance with the practice policy and the recognised guidance and contractual obligations for GP’s in England.
• Undertake a review of significant events and complaints over time to identify trends.
• Most of these areas had been addressed and improvements put in place however we identified that the security of blank prescription pads needed strengthening which the practice was made aware of on the day of the inspection and also that the documentation of significant events needed reviewing and learning from the significant events did not always identify how it drove improvements.

During our inspection in December 2018 we identified actions which the provider had not fully addressed.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Ensure that adequate locum checks are carried out including reassurance of their current immunity status and that safeguarding training is up to date.
• Continue to improve QOF data in relation to those patients with long term conditions.
• Carry out risk assessments in relation to the security of the premises and for the storage of hazardous substances to ensure there is a safe environment for patients and staff.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice