Archived: R J Mitchell Medical Centre

We carried out an announced comprehensive inspection at RJ Mitchell Medical Centre on 6 February 2018. The overall rating for the practice was requires improvement with requires improvement in well led and inadequate in safe. Breaches of legal requirements were found and a warning notice was served in relation to good governance and requirement notices in relation to safe care and treatment and fit and proper persons employed. The full comprehensive report on the February 2018 inspection can be found by selecting the ‘all reports’ link for RJ Mitchell Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 23 April 2018 to confirm that the practice met the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 6 February 2018. We found serious concerns about patient safety, therefore we went back to complete the inspection on 27 and 30 April 2018. We told the practice to submit an action plan by 8 May 2018 to detail how the serious concerns that put patients at risk had been/would be addressed. An action plan was submitted and the provider submitted an application to cancel their registration with the Care Quality Commission. Should they have remained registered we would have taken greater enforcement action.

Our key findings were as follows:

• Staff that checked the temperature of the vaccine fridge were aware of the correct temperature range for vaccine storage. The practice’s cold chain policy had been updated to include guidance on ensuring the cold chain was maintained when transporting flu vaccines to local care homes.
• Emergency medicines had been reviewed and suggested emergency medicines were held in a central location at the main practice. A formal system to check that the emergency medicines were in date had been implemented.
• A risk assessment had been completed to demonstrate how risks to patients would be mitigated in the absence of recommended emergency medicines taken on GP home visits.
• A system to track the use of prescriptions used in printers throughout the practice had been implemented.
• Legionella risk assessments had been completed and an action plan put in place to mitigate risks identified. Staff had been referred for assessment of staff immunity against health care acquired infections. Risk assessments had been completed where immunity was not present.
• Access arrangements for disabled patients through the entrance doors of the practices had been reviewed.
• Patients told us they were treated with dignity and respect and there was easy access to appointments.
• Systems to safeguard vulnerable adults and children from the risk of abuse were not effective.
• An effective system to ensure the monitoring of patients on high risk medicines was not in place.
• Systems to monitor the collection of repeat prescriptions were not effective.
• Systems for the prescribing of controlled medicines were not effective and did not keep patients safe.
• A clear process in regard to the receipt, analysis and response to Medicines and Healthcare products Regulatory Agency (MHRA) was not in place.
• Patients with infections did not always receive recommended treatment or investigations.
• Staff recruitment checks did not meet legal requirements. There was no formal system in place to monitor that professional registrations were in date. Medical indemnity cover for clinical staff had been put in place.
• Patients with a learning disability had been offered a review of their health however care plans had not been put in place. Care plans were not in place for patients receiving end of life care or patients experiencing poor mental health.
• Patient referral letters to other services, completed by administrative staff, contained inadequate medical histories and examination findings and were not signed or checked by a GP before being sent.
• There were systems for reviewing and investigating when things went wrong however the learning identified was not always applied to practice.
• A clearly defined strategy to deliver the practice’s vision had not been put in place.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure specified information is available regarding each person employed.
• Ensure, where appropriate, persons employed are registered with the relevant professional body.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Develop a clearly defined strategy to deliver the practice’s vision.

We found several risks we identified at our previous inspection had not been effectively mitigated. In particular:

• Incomplete recruitment checks.
• A system to monitor professional registrations were in date had not been implemented.
• An effective system to ensure the monitoring of patients on high risk medicines was not in place.
• Systems to monitor the collection of repeat prescriptions were not effective.
• A clear process in regard to the receipt, analysis and response to Medicines and Healthcare products Regulatory Agency (MHRA) was not in place.
• A clearly defined strategy to deliver the practice’s vision was not in place.

For further information, please refer to the evidence table that accompanies this report.

At our previous inspection we rated the practice as inadequate in delivering safe services. At this inspection we found the service had failed to make sufficient improvement, and remains rated as inadequate for delivering safe services. The practice is also rated inadequate in well led and inadequate overall.

I am placing this service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have 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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? –Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at RJ Mitchell Medical Centre on 6 February 2018 as part of our inspection programme.

At this inspection we found:

• When incidents happened, the practice learned from them and improved their processes.

• The practice had systems to keep patients safe and safeguarded from the risk of abuse. However, the safeguarding policy for vulnerable adults did not reflect the most up to date guidance.

• Staff recruitment checks did not meet legal requirements.

• The management of emergency or high risk medicines, repeat prescriptions and vaccines did not always promote the safety of patients. Systems to ensure a clear process in regard to the receipt, analysis and response to Medicines and Healthcare products Regulatory Agency (MHRA) were not effective.

• There was evidence of actions taken to support good antimicrobial stewardship.

• Infection control audits and action plans had been completed to promote a clean and appropriate environment. However, risk assessments for legionella and how patients and staff would be protected in the absence of assessment of staff immunity against health care acquired infections was not present for all members of staff.

• The practice had a system in place to monitor training completed by staff. Some staff had not received mandatory training as identified by the practice.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. However, there was no system in place to review the health of patients with a learning disability.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Most patients found the appointment system easy to use and reported they were able to access care when they needed it. However, arrangements for disabled patients to enter the practice’s front doors needed to be reviewed.

• The practice were forging links with the voluntary sector. The patient participation group was very active.

• Staff had clear roles and responsibilities but not all staff were aware of the practice vision.

• There were gaps in the practice’s governance systems and processes.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

• Ensure specified information is available regarding each person employed.

• Ensure, where appropriate, persons employed are registered with the relevant professional body.

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

For details, please refer to the requirement notices at the end of this report.

The areas where the provider should make improvements are:

• Attain confirmation that medical indemnity cover for the practice nurses has been completed.

• Review access arrangements for disabled patients through the front door.

• Implement a clearly defined strategy to make staff aware of the practice’s vision.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice