Groombridge and Medical Group Quality Report

Hartfield Village Surgery Old Crown Farm East TN7 4AD Tel: 01892 863326 Date of inspection visit: 8 June 2016 Website: www.groombridgeandhartfieldmedicalgroupDat.coe.ukof publication: 23/09/2016

This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations.

Ratings

Overall rating for this service Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Good –––

1 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

Contents

Summary of this inspection Page Overall summary 2 The five questions we ask and what we found 4 The six population groups and what we found 7 What people who use the service say 11 Areas for improvement 11 Outstanding practice 11 Detailed findings from this inspection Our inspection team 12 Background to Groombridge and Hartfield Medical Group 12 Why we carried out this inspection 12 How we carried out this inspection 12 Detailed findings 14 Action we have told the provider to take 23

Overall summary

Letter from the Chief Inspector of General been trained to provide them with the skills, Practice knowledge and experience to deliver effective care and treatment, though gaps in training were identified We carried out an announced comprehensive inspection in relation to fire safety. at Groombridge and Hartfield Medical Group on 8 June • Patients said they were treated with compassion, 2016. Overall the practice is rated as requires dignity and respect and they were involved in their improvement. care and decisions about their treatment. Our key findings across all the areas we inspected were as • Information about services and how to complain was follows: available and easy to understand. Improvements were made to the quality of care as a result of complaints • There was an open and transparent approach to safety and concerns. and an effective system in place for reporting and • Patients said they found it easy to make an recording significant events. appointment with a named GP and there was • Certain areas of building management had not been continuity of care, with urgent appointments available checked at the appropriate intervals and the provider the same day. had not always acted on safety recommendations • The practice had good facilities and was well equipped made as a result of reviews. to treat patients and meet their needs. • Staff assessed patients’ needs and delivered care in • There was a clear leadership structure and staff felt line with current evidence based guidance. Staff had supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

2 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

• The provider was aware of and complied with the • To ensure that all safety assessments are undertaken requirements of the duty of candour. and reviewed as required. We saw one area of outstanding practice: • To ensure that appropriate training for staff is completed and monitored. This includes training in • The two partner GPs disclosed their personal contact respect of fire safety. details to all palliative care patients so as to ensure that these patients could be supported fully and to The area where the provider should make improvements ensure they received the best care available. is: The areas where the provider must make improvement • To actively identify patients that have caring are: responsibilities within the patient list. • Ensure that medicines management systems are Professor Steve Field (CBE FRCP FFPH FRCGP) reviewed to protect patients against the risk of Chief Inspector of General Practice unsafe care and treatment.

3 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

The five questions we ask and what we found

We always ask the following five questions of services.

Are services safe? Requires improvement ––– The practice is rated as requires improvement for providing safe services. • There was an effective system in place for reporting and recording significant events • Lessons were shared to make sure action was taken to improve safety in the practice. • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again. • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, the practice had undertaken a fire risk assessment in 2015 which identified issues but no action plan was provided which resolved these issues. The practice did not have an electrical installation assessment in place. • The systems in place for managing medicines were not safe particularly in regard to receiving and acting on medicine alerts, supplying correct information on medicines when filling drug dosette boxes, the documentation of controlled drugs, the dispensing of controlled drugs and the timely disposal of controlled drugs.

Are services effective? Requires improvement ––– The practice is rated as requires improvement for providing effective services. • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average. • Staff assessed needs and delivered care in line with current evidence based guidance. • Clinical audits demonstrated quality improvement. • Staff had the skills, knowledge and experience to deliver effective care and treatment. • There was evidence of appraisals and personal development plans for all staff.

4 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. • There were gaps identified in staff training in relation to fire safety training.

Are services caring? Good ––– The practice is rated as good for providing caring services. • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. For example, the percentage of respondents to the GP patient survey who described the overall experience of their GP surgery as fairly good or very good was 94% compared to the CCG average of 89% and the national average of 85%. • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. • Information for patients about the services available was easy to understand and accessible. • Both partner GPs disclosed their personal contact details to patients who were on the palliative care register to ensure these patients could make contact with a GP at any time of the day. • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Are services responsive to people’s needs? Good ––– The practice is rated as good for providing responsive services. • Practice staff reviewed the needs of its local population and engaged with the NHS Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. • The practice had good facilities and was well equipped to treat patients and meet their needs. • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Are services well-led? Good ––– The practice is rated as good for being well-led.

5 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

• The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it. • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active. • There was a focus on continuous learning and improvement at all levels.

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The six population groups and what we found

We always inspect the quality of care for these six population groups.

Older people Requires improvement ––– The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • The practice offered proactive, personalised care to meet the needs of the older people in its population. • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. • The practice held fortnightly meetings with district nurses and the advanced community nurse practitioner to discuss patients and ensure care plans were complete. • The practice held a register for those patients at risk of an unplanned admission and these patients had a care plan and alert placed on their file should they be treated by a GP who was not familiar to them.

People with long term conditions Requires improvement ––– The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. • Performance for diabetes related indicators was 100%, which was better than the CCG average of 90% and national average of 89%.For example, data from 2014/15 showed that the percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months was 94% compared to the CCG average of 87% and a national average of 88%. • Longer appointments and home visits were available when needed. • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met.

7 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

• For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. • Patients that were on the practice’s palliative care record were given both GP partners personal contact details so that they could obtain assistance 24 hours a day. • The practice operated a “Birthday” review scheme so patients requiring annual assessments for their conditions received a personalised invitation during the month of their birthday, depending on their condition, detailing what blood tests they will need and how they will subsequently be followed by either the practice nurse or a doctor.

Families, children and young people Requires improvement ––– The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. • Immunisation rates were comparable to local averages for most standard childhood immunisations. Systems were in place to follow up patients who did not attend. • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. • The practice’s uptake for the cervical screening programme was 80%, which was comparable to the CCG average of 83% and the national average of 82%. Patients that did not attend their planned appointment were contacted by telephone to discuss any concerns. • Appointments were available outside of school hours and the premises were suitable for children and babies. • We saw positive examples of joint working with midwives and health visitors.

8 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

Working age people (including those recently retired and Requires improvement ––– students) The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. • Extended hours appointments were available from 7am on Wednesday mornings and from 7pm and 8.30pm on Wednesday evenings. Saturday morning appointments were available twice monthly from 7am to 8.30am.

People whose circumstances may make them vulnerable Requires improvement ––– The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • The practice offered longer appointments for patients with a learning disability. • The practice regularly worked with other health care professionals in the case management of vulnerable patients. • The practice informed vulnerable patients about how to access various support groups and voluntary organisations. • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. • Both GP partners gave palliative care patients their personal contact details and ensured that these patients could obtain assistance whenever required.

9 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Summary of findings

People experiencing poor mental health (including people Requires improvement ––– with dementia) The provider was rated as requires improvement for safe and effective and good for caring, responsive and well led. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice. • 83% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average of 84%. • Data showed that the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had had a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 94% which was better than the national average of 88%. • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. • The practice carried out advance care planning for patients with dementia. • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health. • Staff had a good understanding of how to support patients with mental health needs and dementia.

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What people who use the service say

The national GP patient survey results were published in We received 38 comment cards which were all positive January 2016. The results showed the practice was about the standard of care received. Some comments performing in line with local and national averages. 269 that were made included all staff treated people with survey forms were distributed and 129 were returned. dignity and respect. We received a number of positive This represented 2.5% of the practice’s patient list. comments about the reception staff and patients said they were made to feel welcome. The practice was noted • 90% of patients found it easy to get through to this for having a peaceful environment and for cleanliness. practice by phone compared to the national average of 73%. We spoke with 11 patients during the inspection. Nine • 81% of patients were able to get an appointment to Patients said they were satisfied with the care they see or speak to someone the last time they tried received and thought staff were approachable, compared to the national average of 76%. committed and caring though comments were made that • 94% of patients described the overall experience of it was sometimes difficult to obtain appointments and this GP practice as good compared to the national appointments would often overrun. Two patients stated average of 85%. that it was not easy to get appointments and one had • 95% of patients said they would recommend this GP already complained to the practice regarding this issue. practice to someone who has just moved to the local The response from the family and friends test of May 2016 area compared to the national average of 79%. showed that from 14 responses 13 were either very likely or likely to recommend the practice. There was one As part of our inspection we also asked for CQC comment response that was neutral. cards to be completed by patients prior to our inspection.

Areas for improvement

Action the service MUST take to improve • To ensure that appropriate training for staff is completed and monitored. This includes training in • Ensure that medicines management systems are respect of fire safety. reviewed to protect patients against the risk of unsafe care and treatment. Action the service SHOULD take to improve • To ensure that all safety assessments are undertaken • To actively identify patients that have caring and reviewed as required. responsibilities within the patient list.

Outstanding practice

• The two partner GPs disclosed their personal contact details to all palliative care patients so as to ensure that these patients could be supported fully and to ensure they received the best care available.

11 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Groombridge and Hartfield Medical Group Detailed findings

The practice runs a number of services for its patients Our inspection team including asthma clinics, diabetes clinics, coronary heart disease clinics, minor surgery, child immunisation clinics, Our inspection team was led by: new patient checks and travel vaccines and advice. Our inspection team was led by a CQC Lead Inspector. Services are provided from two locations: The team included a GP specialist adviser, a CQC Hartfield Village Surgery, Old Crown Farm, , TN7 pharmacy inspector, a practice manager specialist 4AD adviser and an Expert by Experience. And a branch surgery at: Groombridge Surgery, Road, Groombridge, Background to Groombridge Tunbridge Wells, TN3 9QP and Hartfield Medical Group We did not inspect the branch surgery on the day of inspection. However, the pharmacy inspector did inspect Groombridge and Hartfield Medical Group is a dispensing the dispensary at the branch location. practice offering general medical services to the population of Groombridge, Hartfield and surrounding areas in East Opening hours are Monday to Friday 8am to 1pm and 2pm Sussex. There are approximately 5,100 registered patients. to 6.30pm Monday, Tuesday, Wednesday and Friday. The practice is closed Thursday afternoon though patient can The practice population has a higher number of patients attend the Groombridge surgery for appointments. The between 45-85 years and over compared to the national practice has extended hours with evening sessions until and local CCG averages. The practice population also 8pm on the 2nd, 3rd and 4th Wednesday of each month shows a lower number of patients between the age of and early morning appointments from 7am on the 1st, 2nd 15-39 years compared to the national and local CCG and 4th Wednesday of each month. Saturday morning averages. There are a slightly higher number of patients appointments are available from 7am to 8.15am on the first with a longstanding health conditions. The percentage of Saturday of each month and between 8am and 9.15am on registered patients suffering deprivation (affecting both the third Saturday of each month. adults and children) is lower than the average for both the CCG area and England. During the times when the practice is closed arrangements are in place for patients to access care from IC24 which is Groombridge and Hartfield Medical Group is run by two an Out of Hours provider. male partner GPs. The practice is also supported by three female salaried GPs; three practice nurses, one healthcare assistant, two phlebotomists, a dispensary team, a team of administrative and reception staff, and a locum practice manager.

12 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Detailed findings

• Reviewed comment cards where patients and members Why we carried out this of the public shared their views and experiences of the service. inspection To get to the heart of patients’ experiences of care and We carried out a comprehensive inspection of this service treatment, we always ask the following five questions: under Section 60 of the Health and Social Care Act 2008 as • Is it safe? part of our regulatory functions. The inspection was • Is it effective? planned to check whether the provider is meeting the legal • Is it caring? requirements and regulations associated with the Health • Is it responsive to people’s needs? and Social Care Act 2008, to look at the overall quality of • Is it well-led? the service, and to provide a rating for the service under the Care Act 2014. We also looked at how well services were provided for specific groups of people and what good care looked like How we carried out this for them. The population groups are: • Older people inspection • People with long-term conditions • Families, children and young people Before visiting, we reviewed a range of information we hold • Working age people (including those recently retired about the practice and asked other organisations to share and students) what they knew. We carried out an announced visit on 8 • People whose circumstances may make them June 2016. During our visit we: vulnerable • Spoke with a range of staff including four GPs, two • People experiencing poor mental health (including nurses, one healthcare assistant, two reception and people with dementia). administration staff, the dispensary manager and the Please note that when referring to information throughout locum practice manager. this report, for example any reference to the Quality and • We spoke with eleven patients who used the service. Outcomes Framework data, this relates to the most recent • Observed how patients were being cared for and talked information available to the CQC at that time. with carers and/or family members • Reviewed an anonymised sample of the personal care or treatment records of patients.

13 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Requires improvement –––

Are services safe?

Staff demonstrated they understood their Our findings responsibilities and all had received training on safeguarding children and vulnerable adults relevant to Safe track record and learning their role. GPs were trained to child protection or child There was an effective system in place for reporting and safeguarding level three. Nurses had been trained to recording significant events. level two though one nurse had also been trained to level three. • Staff told us they would inform the practice manager of any incidents and there was a recording form available • A notice in the waiting room advised patients that on the practice’s computer system. The incident chaperones were available if required. All staff who recording form supported the recording of notifiable acted as chaperones were trained for the role and had incidents under the duty of candour. (The duty of received a Disclosure and Barring Service (DBS) check. candour is a set of specific legal requirements that (DBS checks identify whether a person has a criminal providers of services must follow when things go wrong record or is on an official list of people barred from with care and treatment). working in roles where they may have contact with • We saw evidence that when things went wrong with care children or adults who may be vulnerable). and treatment, patients were informed of the incident, • The practice maintained appropriate standards of received reasonable support, truthful information, a cleanliness and hygiene. We observed the premises to written apology and were told about any actions to be clean and tidy. The practice nurse was the infection improve processes to prevent the same thing happening control clinical lead who liaised with the local infection again. prevention teams to keep up to date with best practice. • The practice carried out a thorough analysis of the There was an infection control protocol in place and significant events. staff had received up to date training. Annual infection control audits were undertaken and we saw evidence We reviewed safety records, incident reports, patient safety that action was taken to address any improvements alerts and minutes of meetings where these were identified as a result. discussed. We saw evidence that lessons were shared and • The arrangements for managing medicines (obtaining, action was taken to improve safety in the practice. For prescribing, recording, handling, storing and security) example, information regarding the need for paracetamol did not always keep people safe. to be given following a specific immunisation did not occur • Medicines were stored securely at both sites. Both sites at the time of the appointment. This error was realised and held emergency medicines and oxygen. Although these the parents informed. The practice discussed this case and were within their expiry dates at Hartfield practice, we a template is now used for this immunisation where it has found an out of date emergency medicine at to be stated that this information has been passed on. Groombridge practice. Medicines which required Overview of safety systems and processes refrigeration were kept between 2°C and 8°C and records were available to demonstrate this. The practice The practice had clearly defined and embedded systems, had not consistently received medicines safety alerts processes and practices in place to keep patients safe and and recalls since October 2014. safeguarded from abuse, which included: • Arrangements for controlled drugs (CDs - medicines • Arrangements were in place to safeguard children and which are more liable to misuse and so need closer vulnerable adults from abuse. These arrangements monitoring) were not appropriate. Staff showed us reflected relevant legislation and local requirements. records for ordering, receipt and supply of CDs. Records Policies were accessible to all staff. The policies clearly in the controlled drugs register did not meet legal outlined who to contact for further guidance if staff had requirements. Expired CDs had not been disposed of in concerns about a patient’s welfare. There was a lead a timely manner. The practice was aware of these member of staff for safeguarding. The GPs attended historical issues and was already taking steps to tighten safeguarding meetings when possible and always processes and improve staff training to ensure that provided reports where necessary for other agencies.

14 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Requires improvement –––

Are services safe?

future records would be accurate. They had also Risks to patients were assessed and well managed. nominated a GP to lead on CD governance in future. The • There were procedures in place for monitoring and practice was also in the process of arranging destruction managing risks to patient and staff safety. The practice of expired CDs. provided evidence that a fire risk assessment had been • We also found an unsigned prescription for a CD that undertaken in August 2015, this assessment identified had been dispensed and was awaiting collection. This is gaps in staff training and did not contain an action plan important to ensure the medicine is appropriate for the to resolve these issues. We saw evidence that regular fire person who is in receipt of the prescribed medicine and drills had taken place but no record had been to guard against inappropriate use of CDs. maintained to document who had taken part in these. • Staff involved in dispensing activities were trained to an All portable electrical equipment was checked in August appropriate level and had appraisals annually. The 2015 to ensure the equipment was safe to use and dispensary manager had also initiated informal training clinical equipment was checked in July 2015 to ensure it for staff on how to correctly use information resources was working properly. The practice had a variety of on medicines. The practice used standard operating other risk assessments booked to be undertaken to procedures (SOPs) for dispensing; these were reviewed monitor safety of the premises such as an electrical annually. As these were new, staff had not yet signed installation assessment, gas boiler assessment and them. legionella assessment which we noted were all planned • The practice dispensed medicines into for June 2016, (Legionella is a term for a particular multi-compartment compliance aids (dosette boxes) for bacterium which can contaminate water systems in some people. The information sheet provided with the buildings). dosette box did not give details of the identity (colour, • Arrangements were in place for planning and shape, markings) of the different tablets or capsules monitoring the number of staff and mix of staff needed which had been dispensed. The practice was in the to meet patients’ needs. There was a rota system in process of changing what information was given to place for all the different staffing groups to ensure people. enough staff were on duty. • Prescription forms (FP10s) were stored securely. Prescriptions forms for use in printers were actively Arrangements to deal with emergencies and major tracked through the practice. Staff followed appropriate incidents procedures to ensure vaccines were administered safely. The practice had adequate arrangements in place to • Staff demonstrated that they followed procedures to respond to emergencies and major incidents. make sure patients could not obtain medicines which were not on a repeat order or needed further checks • There was an instant messaging system on the (such as a blood test) without consulting a GP. We saw computers in all the consultation and treatment rooms records of dispensing errors; staff were able to give which alerted staff to any emergency. examples of learning as a result of these. Formal • All staff received annual basic life support training and recording of near misses (dispensing errors which do there were emergency medicines available in the not reach a patient) had just begun at the practice. The treatment room. dispensary manager had also put in place informal • The practice had a defibrillator available on the meetings to ensure staff could talk about errors and premises and oxygen with adult and children’s masks. A near misses. first aid kit and accident book were available. • We reviewed five personnel files and found appropriate • Emergency medicines were easily accessible to staff in a recruitment checks had been undertaken prior to secure area of the practice and all staff knew of their employment. For example, proof of identification, location. All the medicines we checked were in date and references, qualifications, registration with the stored securely. appropriate professional body and the appropriate • The practice had a comprehensive business continuity checks through the Disclosure and Barring Service. plan in place for major incidents such as power failure or building damage. The plan included emergency Monitoring risks to patients contact numbers for staff.

15 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Requires improvement ––– Are services effective? (for example, treatment is effective)

• There had been five clinical audits completed in the last Our findings two years, three of these were completed audits where the improvements made were implemented and Effective needs assessment monitored. The practice assessed needs and delivered care in line with • The practice participated in local audits, national relevant and current evidence based guidance and benchmarking, accreditation, peer review and research. standards, including National Institute for Health and Care • Findings were used by the practice to improve services. Excellence (NICE) best practice guidelines. For example, recent action taken as a result included reviewing the care patients received for their diabetes • The practice had systems in place to keep all clinical thus improving areas such as cholesterol levels which staff up to date. Staff had access to guidelines from NICE impact on coronary heart disease. and used this information to deliver care and treatment that met patients’ needs. Information about patients’ outcomes was used to make • The practice monitored that these guidelines were improvements such as improving the palliative care followed through risk assessments, audits and random provided for patients by ensuring that anticipatory sample checks of patient records. medication was available for patients thus decreasing the need for an unplanned admission. Management, monitoring and improving outcomes for people Effective staffing The practice used the information collected for the Quality Staff had the skills, knowledge and experience to deliver and Outcomes Framework (QOF) and performance against effective care and treatment. national screening programmes to monitor outcomes for • The practice had an induction programme for all newly patients. (QOF is a system intended to improve the quality appointed staff. This covered such topics as of general practice and reward good practice). The most safeguarding, infection prevention and control, fire recent published results were 98.1% of the total number of safety, health and safety and confidentiality. However, it points available. was noted that there were gaps in some staffs training in This practice was not an outlier for any QOF (or other relation to fire training. national) clinical targets. Data from 2014/15 showed: • The practice could demonstrate how they ensured role-specific training and updating for relevant staff. For • Performance for diabetes related indicators was better example, for those reviewing patients with long-term that the national average. For example, the percentage conditions. of patients on the diabetes register, with a record of a • Staff administering vaccines and taking samples for the foot examination and risk classification within the cervical screening programme had received specific preceding 12 months was 94% compared to the training which had included an assessment of national average of 88%. competence. Staff who administered vaccines could • Performance for mental health related indicators was demonstrate how they stayed up to date with changes also better than the national average. For example, the to the immunisation programmes, for example by percentage of patients with schizophrenia, bipolar access to on line resources and discussion at practice affective disorder and other psychoses who had a meetings. comprehensive, agreed care plan documented in the record, in the preceding 12 months was 94% compared • The learning needs of staff were identified through a to the national average of 88%. system of appraisals, meetings and reviews of practice • The practice had a system in place for patients with long development needs. Staff had access to appropriate term conditions which sent out a personalised invitation training to meet their learning needs and to cover the to attend for an annual review on the month of the scope of their work. This included ongoing support, patient’s birthday. one-to-one meetings, clinical supervision and facilitation and support for revalidating GPs. All staff had There was evidence of quality improvement including received an appraisal within the last 12 months. clinical audit.

16 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Requires improvement ––– Are services effective? (for example, treatment is effective)

• Staff received training that included: safeguarding, fire The practice identified patients who may be in need of safety awareness, basic life support and information extra support. For example: governance. Staff had access to and made use of • Patients receiving end of life care, carers, those at risk of e-learning training modules and in-house training. developing a long-term condition and those requiring Coordinating patient care and information sharing advice on their diet, smoking and alcohol cessation. Patients were signposted to the relevant service. The information needed to plan and deliver care and • A dietician was available on the premises and smoking treatment was available to relevant staff in a timely and cessation advice was available from a local support accessible way through the practice’s patient record system group. and their intranet system. The practice’s uptake for the cervical screening programme • This included care and risk assessments, care plans, was 79%, which was comparable to the CCG average of medical records and investigation and test results. 83% and the national average of 83%. There was a policy to • The practice shared relevant information with other offer telephone reminders for patients who did not attend services in a timely way, for example when referring for their cervical screening test. The practice ensured a patients to other services. female sample taker was available. The practice also Staff worked together and with other health and social care encouraged its patients to attend national screening professionals to understand and meet the range and programmes for bowel and breast cancer screening. For complexity of patients’ needs and to assess and plan example Female patients aged 50-70, that were screened ongoing care and treatment. This included when patients for breast cancer in the last 36 months (three year moved between services, including when they were coverage) was 72% which was comparable to the CCG referred, or after they were discharged from hospital. average of 75% and a national average of 72%. Also, Meetings took place with other health care professionals on Patients aged between 60-69, screened for bowel cancer in a monthly basis when care plans were routinely reviewed the last 30 months was 58% which was lower than the the and updated for patients with complex needs. local CCG average of 62% and the same as the national average of 58%. There were failsafe systems in place to Consent to care and treatment ensure results were received for all samples sent for the Staff sought patients’ consent to care and treatment in line cervical screening programme and the practice followed up with legislation and guidance. women who were referred as a result of abnormal results. • Staff understood the relevant consent and Childhood immunisation rates for the vaccines given were decision-making requirements of legislation and comparable to CCG averages. For example, childhood guidance, including the Mental Capacity Act 2005. immunisation rates for the vaccines given to under two • When providing care and treatment for children and year olds ranged from 71% to 93% and five year olds from young people, staff carried out assessments of capacity 75% to 94% compared to the CCG averages of 90% to 94% to consent in line with relevant guidance. and 88% to 94% respectively. During the inspection the • Where a patient’s mental capacity to consent to care or practice showed us evidence of under two year old treatment was unclear the GP or practice nurse childhood immunisations ranging from 86% to 100%.. assessed the patient’s capacity and, recorded the Patients had access to appropriate health assessments and outcome of the assessment. checks. These included health checks for new patients and • The process for seeking consent was monitored through NHS health checks for patients aged 40–74. Appropriate patient records audits. follow-ups for the outcomes of health assessments and Supporting patients to live healthier lives checks were made, where abnormalities or risk factors were identified.

17 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Good –––

Are services caring?

• 99% of patients said they had confidence and trust in Our findings the last GP they saw compared to the CCG average of 97% and the national average of 95%. Kindness, dignity, respect and compassion • 96% of patients said the last GP they spoke to was good We observed members of staff were courteous and very at treating them with care and concern compared to the helpful to patients and treated them with dignity and national average of 85%. respect. • 97% of patients said the last nurse they spoke to was good at treating them with care and concern compared • Curtains were provided in consulting rooms to maintain to the national average of 91%. patients’ privacy and dignity during examinations, • 95% of patients said they found the receptionists at the investigations and treatments. practice helpful compared to the CCG average of 88% • We noted that consultation and treatment room doors and the national average of 87%. were closed during consultations; conversations taking place in these rooms could not be overheard. Care planning and involvement in decisions about • Reception staff knew when patients wanted to discuss care and treatment sensitive issues or appeared distressed they could offer Patients told us they felt involved in decision making about them a private room to discuss their needs. the care and treatment they received. They also told us • Both GP partners ensured palliative care patients could they felt listened to and supported by staff and had contact them at any time by disclosing their personal sufficient time during consultations to make an informed contact details to these patients. decision about the choice of treatment available to them. • The practice operated a “TLC” board within the surgery Patient feedback from the comment cards we received was to identify patients who may need additional support, also positive and aligned with these views. We also saw for example, patients who were also carers or on the that care plans were personalised. palliative care register. Results from the national GP patient survey showed All of the 38 patient Care Quality Commission comment patients responded positively to questions about their cards we received were positive about the service involvement in planning and making decisions about their experienced. Patients said they felt the practice offered an care and treatment. Results were in line with local and excellent service and staff were helpful, caring and treated national averages. For example: them with dignity and respect. • 97% of patients said the last GP they saw was good at We spoke with three members of the patient participation explaining tests and treatments compared to the CCG group (PPG). They also told us they were satisfied with the average of 90% and the national average of 86%. care provided by the practice and said their dignity and • 97% of patients said the last GP they saw was good at privacy was respected. Comment cards highlighted that involving them in decisions about their care compared staff responded compassionately when they needed help to the national average of 82%. and provided support when required. • 93% of patients said the last nurse they saw was good at Results from the national GP patient survey showed involving them in decisions about their care compared patients felt they were treated with compassion, dignity to the national average of 85%. and respect. The practice was above average for its The practice provided facilities to help patients be involved satisfaction scores on consultations with GPs and nurses. in decisions about their care: For example: • Information leaflets were available in easy read format. • 97% of patients said the GP was good at listening to • The practice used care plans to understand and meet them compared to the clinical commissioning group the emotional, social and physical needs of patients, (CCG) average of 93% and the national average of 89%. including those at high risk of hospital admission. We • 96% of patients said the GP gave them enough time compared to the CCG average of 91% and the national average of 87%.

18 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Good –––

Are services caring?

were shown anonymised examples of care plans and The practice’s computer system alerted GPs if a patient was noted these were detailed and personalised. For those also a carer. The practice had identified 40 patients as patients unable to attend the practice, GPs would carry carers (approximately 1% of the practice list). Written out home visits to complete care plans. information was available to direct carers to the various avenues of support available to them. Patient and carer support to cope emotionally with care and treatment Staff told us that if families had suffered bereavement, their usual GP contacted them. This call was either followed by a Patient information leaflets and notices were available in patient consultation at a flexible time and location to meet the patient waiting area which told patients how to access the family’s needs or by giving them advice on how to find a a number of support groups and organisations. support service. Information about support groups was also available on the practice website.

19 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Good ––– Are services responsive to people’s needs? (for example, to feedback?)

• 81% of patients were satisfied with the practice’s Our findings opening hours compared to the national average of 78%. Responding to and meeting people’s needs • 90% of patients said they could get through easily to the The practice reviewed the needs of its local population and practice by phone compared to the national average of engaged with the NHS England Area Team and Clinical 73%. Commissioning Group (CCG) to secure improvements to People told us on the day of the inspection that they were services where these were identified. able to get appointments when they needed them. • The practice offered extended hours appointments at The practice had a system in place to assess: various times for patients who could not attend during normal opening hours. • whether a home visit was clinically necessary; and • There were longer appointments available for patients • the urgency of the need for medical attention. with a learning disability. Requests for home visits were reviewed by a GP. In cases • Home visits were available for older patients and where the urgency of need was so great that it would be patients who had clinical needs which resulted in inappropriate for the patient to wait for a GP home visit, difficulty attending the practice. alternative emergency care arrangements were made. • Same day appointments were available for children and Clinical and non-clinical staff were aware of their those patients with medical problems that require same responsibilities when managing requests for home visits. day consultation. • Patients were able to receive travel vaccinations Listening and learning from concerns and complaints available on the NHS as well as those only available The practice had an effective system in place for handling privately/were referred to other clinics for vaccines complaints and concerns. available privately. • There were disabled facilities and hearing loop • Its complaints policy and procedures were in line with available. recognised guidance and contractual obligations for GPs in England. Access to the service • There was a designated responsible person who The practice was open between 8am and 6.30pm Monday handled all complaints in the practice. to Friday. Appointments were from 8am to 1pm every • We saw that information was available to help patients morning and 2pm to 6.30pm Monday, Tuesday, Wednesday understand the complaints system. The complaints and Friday. Patients could access appointments Thursday procedure was available in the practice and on their afternoon from the Groombridge practice. Extended hours website. The procedure gave patients information on appointments were offered at the following times, from how to escalate a complaint if they were not satisfied 7am on the 1st, 2nd and 4th Wednesday of each month with the response from the practice. The procedure from Groombridge Surgery and until 8pm on the 2nd, 3rd could be translated into different languages via the and 4th Wednesday of each month at Hartfield surgery. practice website. Saturday morning appointments were also available The practice had received five complaints in the last 12 between 7am and 8.15am on the 1st Saturday each month months and we found these were satisfactorily handled at Hartfield surgery and between 8am and 9.15am on the and dealt with in a timely way. The complaints had been 3rd Saturday each month at Groombridge surgery. In received in writing, verbally and by feedback via the addition to pre-bookable appointments that could be website. Complaints were discussed and apologies given to booked up to six weeks in advance, urgent appointments patients where appropriate. For example, a complaint was were also available for people that needed them. received following an issue in dispensing medicines when Results from the national GP patient survey showed that proof had not been seen of payment exemption. patient’s satisfaction with how they could access care and Information was issued detailing that there was an option treatment was comparable to local and national averages. to mark the prescription as “no evidence seen” to alleviate any further problems.

20 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Are services well-led? Good ––– (for example, are they well-managed and do senior leaders listen, learn and take appropriate action)

requirements that providers of services must follow when Our findings things go wrong with care and treatment).This included support training for all staff on communicating with Vision and strategy patients about notifiable safety incidents. The partners The practice had a clear vision to deliver high quality care encouraged a culture of openness and honesty. The and promote good outcomes for patients. practice had systems in place to ensure that when things went wrong with care and treatment: • The practice had a mission statement which was displayed in the waiting areas and staff knew and • The practice gave affected people reasonable support, understood the values. truthful information and a verbal and written apology • The practice had a robust strategy and supporting • The practice kept written records of verbal interactions business plans which reflected the vision and values as well as written correspondence. and were regularly monitored. There was a clear leadership structure in place and staff felt Governance arrangements supported by management. The practice had an overarching governance framework • Staff told us the practice held regular team meetings. which supported the delivery of the strategy and good • Staff told us there was an open culture within the quality care. This outlined the structures and procedures in practice and they had the opportunity to raise any place and ensured that: issues at team meetings and felt confident and supported in doing so. • There was a clear staffing structure and that staff were • Staff said they felt respected, valued and supported, aware of their own roles and responsibilities. particularly by the partners in the practice. All staff were • Practice specific policies were implemented and were involved in discussions about how to run and develop available to all staff. the practice, and the partners encouraged all members • A comprehensive understanding of the performance of of staff to identify opportunities to improve the service the practice was maintained delivered by the practice. • A programme of continuous clinical and internal audit was used to monitor quality and to make Seeking and acting on feedback from patients, the improvements. public and staff • There were arrangements for identifying, recording and The practice encouraged and valued feedback from managing risks, issues and implementing mitigating patients, the public and staff. It proactively sought patients’ actions. However, there were areas that required feedback and engaged patients in the delivery of the improving such as, some assessments for measuring service. risk had lapsed, the controlled drugs register did not meet legal requirements and controlled drugs had not • The practice had gathered feedback from patients been disposed of in a timely manner. through the patient participation group (PPG) and through surveys and complaints received. The PPG met Leadership and culture regularly, carried out patient surveys and submitted On the day of inspection the partners in the practice proposals for improvements to the practice demonstrated they had the experience, capacity and management team. For example, Saturday morning capability to run the practice and ensure high quality care. appointments were as a result of PPG involvement. They told us they prioritised safe, high quality and • The practice had gathered feedback from staff through compassionate care. Staff told us the partners were staff meetings, appraisals and discussion. Staff told us approachable and always took the time to listen to all they would not hesitate to give feedback and discuss members of staff. any concerns or issues with colleagues and The provider was aware of and had systems in place to management. Staff told us they felt involved and ensure compliance with the requirements of the duty of engaged to improve how the practice was run. candour. (The duty of candour is a set of specific legal Continuous improvement

21 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 Are services well-led? Good ––– (for example, are they well-managed and do senior leaders listen, learn and take appropriate action)

There was a focus on continuous learning and improvement at all levels within the practice. The practice team was forward thinking and part of local pilot schemes to improve outcomes for patients in the area.

22 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 This section is primarily information for the provider

Requirement notices

Action we have told the provider to take The table below shows the legal requirements that were not being met. The provider must send CQC a report that says what action they are going to take to meet these requirements.

Regulated activity Regulation

Diagnostic and screening procedures Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment Family planning services How the regulation was not being met: Maternity and midwifery services The provider had not ensured prescriptions for Surgical procedures controlled drugs were signed prior to collection. Treatment of disease, disorder or injury The provider had not ensured that all controlled drugs were destroyed in a timely manner The controlled drugs register did not conform to legal standards. The dispensary had not consistently received and acted upon medicine alerts since October 2014. The provider had not supplied the correct information sheet for medicines included within the dosette boxes they had supplied. This was a breach of regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Regulated activity Regulation

Diagnostic and screening procedures Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Safety and suitability of premises Family planning services How the regulation was not being met: Maternity and midwifery services We found that the practice did not have current risk Surgical procedures assessment for electrical installation and did not have a Treatment of disease, disorder or injury current certificate at the time of inspection. This was in breach of regulation 15 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Regulated activity Regulation

23 Groombridge and Hartfield Medical Group Quality Report 23/09/2016 This section is primarily information for the provider

Requirement notices

Diagnostic and screening procedures Regulation 18 HSCA (RA) Regulations 2014 Staffing Family planning services How the regulation was not being met: Maternity and midwifery services We found that the registered provider had not ensured all relevant training with respect to fire safety training Surgical procedures had been undertaken by practice staff. Treatment of disease, disorder or injury This was in breach of regulation 18 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

24 Groombridge and Hartfield Medical Group Quality Report 23/09/2016