CQC Report we were last inspected on Wednesday 7th August 2019 see the report here Full Report

We are pleased that the hard work and dedication of our staff have been recognised in the good rating for the Caring and Responsive domains. However we are disappointed that the CQC judged us to require improvement in the other domains.

We were asked to make improvements in our governance processes and recruitment processes, which we have done. Our new practice manger has been in place since March 2019 and had already identified and been working to correct some of the issues before the inspection Including the Health and Safety report from July 2019, the Fire assessment and staff appraisals.

We want to reassure patients that there is no risk to them and that there were no concerns about patient care raised. The issues raised in the safe domain reflected a failure to demonstrate evidence rather than concerns about patient safety; for example our equipment had been calibrated but the report was not available on the day of inspection.

We recognise that some of our QoF performance was below average but we are disappointed that the CQC did not recognise where our QoF performance is above average e.g. cardiovascular disease, dementia and depression. We are also disappointed that they commented on exception reporting rates without mentioning where our rates are below average.

We have already made the required changes in implementing changes in governance processes and ensuring immunisation records were up to date. Our recruitment processes already ensured all new staff have a DBS check.

Please find below our action plan for the issues identified in the report

1. Fire Risk Assessment – External Fire Risk assessment completed on 17^th October 2019, observations were that we had good practice and low risk. Findings will be implemented and reviewed as recommended by the inspection.

2. Health and Safety Risk Assessment was completed in July 2019, less than a month before the visit.  Actions have been worked through as per the time frame detailed in the report. This will be an annual external assessment.

3. Since receipt of this report we can confirm that we have learnt that a full calibration of all equipment was completed by an external organisation on the 22^nd January 2019. This information was not known at the time of the inspection. We will repeat every year in January.

4. Infection Prevention and Control – Nurse Team working with the CCG Infection Prevention and Control specialist to ensure audit is completed and process for regular review in place.

5. Completed – since the visit two sets of prescription paper lockers have been installed. Each clinician has their own key, takes the paper for the day and at the end of each day returns their prescriptions back. They are locked away overnight.

6. Quality Improvement plan for areas of poor performance –

Quality improvement plan NRMC

Monitoring of Quality

• Performance report developed by end October 2019

• Clinical effectiveness and quality group (CQEG) comprising lead partner, operations manager, lead nurse, and clinic coordinator - established end October 2019.

• Performance report and CEQG report to monthly partners meeting – October 2019

Managing areas of poor performance

• Specific QI programme for areas of poor performance starting with:

• Diabetes

• Asthma

• COPD

• Learning disability checks

• Cervical smears

• Childhood immunisations

• Programme commencing October 2019 and comprises:

• Protected time

• Key stakeholders identified to lead work

• Lead clinician

• Dedicated admin time

• Supported by operations manager

• Initial meeting

• Assessment of current performance

• Identification of areas to target to improve performance (fish diagram, process map etc)

• Identification of change(s) required

• Identification of how to monitor (run chart etc)

• Implement change

• Monthly meetings with PDSA cycle

• Reports to partners meeting and CQEG

A culture change

• Funded partner time to lead on this – starting October 2109

• Audit report to evolve to quality report based on CQC domains – April 2020

• Quality report to be reviewed at practice half day closure - 2020

• All GPs accountable for clinical quality for their registered list around:

• Exception reporting, maximum tolerated etc.

• Repeat non attenders

• Management of complex patients with frailty or multi-morbidity for whom a person centred approach is more appropriate

• Starting November 2019

• QI training for staff as part of standard practice training programme – April 2020

• Aim for RCGP QI ready      

Staff appraisals, supervision and competency checks – In autumn 2019 we are recruiting an Operations Manager to support the governance of the practice and ensure that all staff receive an annual appraisal.

All staff members have a DBS check, the one mentioned above was employed before CRB and DBS checks were introduced, this has now be received and recorded as clear. 

Staff have now produced evidence of their immunisation checks, information contained in a staff matrix.