We carried out an announced comprehensive inspection at Martlesham Heath Surgery on 10 July 2019 as part of our inspection programme. The location had previously been inspected under a different provider. The current provider of the service is Dr Walter Tobias.
This inspection looked at the following key questions:
Are services safe? inadequate
Are services effective? good
Are services caring? good
Are services responsive? good
Are services well led? requires improvement.
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 and good for all population groups.
We found that:
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care and treatment.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The practice worked well with the ‘practice and patient group’ and acted on several suggestions, which had improved the service.
We rated the practice as inadequate for providing safe services because:
- One of the nurses had started employment at the practice in July 2019 and although the Disclosure and Barring Service (DBS) was being applied for, this had not been received at the time of the inspection; the nurse had worked unsupervised with patients and this had not been risk assessed. The practice immediately completed a risk assessment. The practice confirmed this had been received on 16 July 2019.
- Ongoing checks were not undertaken, to ensure clinical staff remained registered with professional bodies.
- Patients who were prescribed medicines which required additional monitoring before being reissued, were not always monitored appropriately. We reviewed the records of eight patients and three patients had not received appropriate monitoring before these were reissued. The practice submitted evidence following the inspection to demonstrate that patients prescribed these medicines had been identified and had since received a blood test or were booked for one.
- The practice was not always reviewing blood monitoring results undertaken in secondary care, before they reissued prescriptions.
- The system to ensure that safety alerts were actioned, and patients reviewed, if appropriate, was not always effective. We reviewed five safety alerts from 2019. Two of these alerts had been acted upon. For one alert, a search had been undertaken on 4 July 2019, and one patient had been identified, although this patient had not been reviewed. The practice agreed to review this patient and submitted evidence following the inspection that this had been completed. The other two alerts, which had been sent to dispensary had not been actioned. These were actioned on the day of the inspection and no patients were affected. Staff advised us during the inspection that they would add a task two days after the alert had been distributed for action, to confirm it was completed.
- There was not an effective failsafe system in place for cervical screening. Following the inspection, the practice provided evidence to show that patients had received a result following a cervical screening test. They planned to undertake this search monthly.
- Two week wait referrals for suspected cancer were documented, but there was no system to check that appointments had been made. Following the inspection, the practice wrote a protocol and planned to code two week wait appointment letters. This was so they could undertake a weekly search to identify and follow up patients who had not received an appointment. The practice had searched for patients who had been referred in the last month and identified two patients whose appointment they would follow up, if it was not received the next day.
- Dispensing Standard Operating Procedures were not up to date and not signed by dispensing staff. There was no SOP for error management and near misses in the dispensary were not documented.
- There was no assessment of the competency of dispensing staff. This was last assessed in 2016.
- The practice recorded the expiry dates of medicines on receipt, and although dispensing staff advised they checked the expiry dates of medicines every three to four months, these checks were not documented.
- One health care assistant had completed safeguarding children training at level one, but had not completed this at level two, and one nurse had not completed safeguarding adult training. One GP had not received infection control training. One of the nurses was not up to date with their childhood immunisation training.
We rated the practice as requires improvement for providing well led services because:
- The governance systems for recording the oversight of staff training was not always effective. Staff had not all completed training deemed mandatory for their role; for example, one health care assistant had only completed safeguarding children training to level one and one nurse had not completed safeguarding adult training. One GP had not received infection control training. One of the nurses was not up to date with their childhood immunisation training.
- The clinical governance systems to ensure that patients prescribed medicines which required a higher level of monitoring, were appropriately monitored, were not always effective.
- The clinical governance systems to ensure that safety alerts were actioned, and patients reviewed if appropriate, was not always effective.
- Staff were not always clear about their roles and responsibilities, which had led to some delays in establishing effective monitoring systems; for example, undertaking fire extinguisher checks and Legionella testing.
- There was not effective oversight of the dispensary service. Standard Operating Procedures were not all relevant, up to date or signed by dispensing staff and near misses were not documented. There was no assessment of the competency of the dispensing staff. This was last assessed in 2016. The practice did not document checks of the expiry dates of medicines. These issues had not been identified by the practice, although once they had been raised, the practice wrote an action plan to address these issues.
We found one area of outstanding practice:
Where vulnerable and frail patients were identified, the practice provided them with a direct mobile telephone number to the practice. Staff received training to ensure this telephone line was responded to within two rings to ensure patients received an appropriate and rapid response to their requests for assistance. This ensured that such patients did not feel isolated.
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.
- Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
The areas where the provider should make improvements are:
- Review arrangements for the security of the dispensary, so that access is limited to dispensing staff and GPs.
- Continue to review the documentation of significant events and complaints and the identified learning was not always clear.
- Progress plans to ensure all staff receive an appraisal.
- Continue to ensure the actions from the fire risk assessment and health and safety audit are completed.
- Continue with the planned review of infection control risks and the audit of the newly implemented cleaning checks and schedules.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care