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3Well Ltd - Botolph Bridge Requires improvement Also known as 3Well Medical

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 December 2017

Letter from the Chief Inspector of General Practice

This was the sixth inspection that we have carried out at 3Well Ltd – Botolph Bridge.

We carried out a comprehensive inspection of 3Well Ltd - Botolph Bridge on 7 May 2015. The practice was rated as good overall with ratings of good for providing safe, caring, and responsive and well led services, and requires improvement for effective services. As a result of the findings on the day of the inspection, the practice was issued with a requirement notice for regulation 17 (good governance).

We carried out a second comprehensive inspection on 10 June 2016. This inspection was in response to concerns raised by members of the public and to check if the practice had made the changes required from the inspection in May 2015. The practice was rated as inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services.

At our June 2016 inspection we found that some of the improvements needed as identified in the report of May 2015 had been made, however, some of these needed to be improved further. Patients were at risk of harm because systems and processes were not in place to keep them safe. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others. As a result of the findings on the day of the inspection, the practice was issued with a warning notice for regulation 12 (safe care and treatment) and requirement notice for regulation 17 (governance and quality assurance). The practice was placed into special measures for six months.

We conducted a focused inspection on 19 August 2016 to ensure that the practice had made the required improvements detailed in the warning notice that had been issued on 8 August 2016.

At our 19 August 2016 inspection we found that some of the improvements needed as identified in the report of June 2016 had been made, however, some of these needed to be improved further. We further identified a new issue relating to the safe prescribing and management of medicines and we were concerned that patients were at risk of harm. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (19 August 2016) we took urgent action to suspend 3Well Ltd Botolph Bridge from providing general medical services at 3Well Ltd Botolph Bridge.

We conducted a focused inspection on 14 November 2016 to check whether the provider had made sufficient improvements and to decide whether the suspension period should end.

At our 14 November 2016 inspection we found that improvements had been made. We saw that a governance framework had been put in place and that medicines were authorised by GPs and nurses with a prescribing qualification. The practice had prioritised patients and had started a process of reviewing patients identified as ‘may be at risk’ from inappropriate reviews. We found that GPs and nurse practitioners managed pathology results and these had been managed in a timely way. The systems and processes in place to ensure good governance had improved but further improvements were needed to enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (14 November 2016) we decided the suspension should end; however, we imposed urgent conditions on the registration of this provider. The ratings remained the same; inadequate overall and the special measures period continued.

We carried out a comprehensive inspection on 13 February 2017. This inspection was undertaken following a period of special measures. The practice was rated requires improvement overall and for providing safe, effective, and responsive services, inadequate for providing well-led services and good for providing caring services. The practice remained in special measures.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 27 October 2017. Overall the practice is now rated as requires improvement. The practice is no longer in special measures.

Our key findings across all the areas we inspected were as follows:

  • Throughout the two periods of special measures, the practice was receiving support from the Royal College of General Practitioners team which consisted of a GP, and an advance nurse practitioner.
  • Since our last inspection all the practice nurses had left and had been replaced.
  • The practice had not been successful in recruiting further principal GPs or salaried GPs; however, they had continued to engage regular locum GPs and had been successful in employing nursing staff, clinical pharmacists, and additional management staff. Due to the shortage of permanent GPs, there was still limited clinical leadership in place.
  • We found that improvements had been made to the systems and processes to ensure management and clinical oversight.
  • The clinical and management team had regular meetings to manage the performance of the practice in relation to the quality and outcomes framework. The practice overall performance for the Quality and Outcomes Framework (QOF) in 2016/17 was 87% compared to 96% in 2015/16. The exception reporting rate for 2016/17 had significantly reduced from 18% in the previous year to 5%.
  • Results from the National GP Patient Survey published in July 2017 showed the practice performance had improved from results published in July 2016 in 12 areas but had remained the same or was lower in eight areas.
  • The practice had been working closely with the CCG and was actively working on pilot projects in the area. The practice had engaged with the local network and was able to book appointments for patients at the local GP Hub.
  • There was a system for recording significant events and complaints; these were discussed at various meetings and actions taken.
  • There was a system in place to ensure regular monitoring of quality and performance and that actions required from hospital correspondence and test results were completed in a timely way.
  • The practice evidenced that there were systems in place to provide clinical oversight of all staff that provide care to patients at the practice.
  • We saw practice protocols and policies were in place and had been updated to reflect the change in clinical leads. However, not all staff found them easy to access.
  • The practice held meetings and encouraged locum clinicians to attend, the practice had introduced and showed evidence that virtual meetings held by email were effective. Staff we spoke with told us they found these useful.
  • Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines including childhood immunisations.
  • The management of medicines had been further improved. The GPs, pharmacists, or nurses who had prescribing qualifications undertook all medicines changes and reviews, including reconciliation of those that had recently been discharged from hospital. We found all patients on high risk medicines had been appropriately monitored.
  • The practice had systems and process in place to record and action safety alerts and these had been well managed.
  • The practice stored prescription stationery securely and had a system in place for tracking its use.
  • The practice used a programme of audits and searches of medical records to monitor and encourage quality improvement.
  • The practice proactively promoted the national cancer screening programmes to encourage uptake.
  • A staff member had taken a lead role as a carer’s champion. This staff member contacted any new carer identified to ensure they were aware of the support that was available to them. The practice had raised the awareness of dementia and had information in several languages available. In addition to a translation service, the practice had staff members who spoke other languages, for example Lithuanian, Polish and German.
  • The practice had engaged the patient participation group to identify and encourage improvement.

There are areas where the provider should make improvements.

  • Continue to build on clinical leadership and active recruitment.
  • Continue to implement and monitor the systems and process to ensure that patients receive appropriate follow ups in a timely manner.
  • Continue to monitor the GP patient survey data and respond to the results appropriately.
  • Review and improve the systems and ensure that staff can access the documents including policies and procedures easily.
  • Continue to identify carers to ensure that they receive appropriate support and care.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 December 2017

The practice is rated as good for providing safe services.

  • There was a clear system for recording significant events and these included both clinical and non-clinical incidents. Practice staff we spoke with told us they felt confident to raise any concerns.
  • The practice had defined systems, processes, and practices in place to keep patients safe and safeguarded from abuse.
  • The practice had implemented systems and processes to monitor and ensure that test results and hospital correspondence were dealt with in a timely manner.
  • The management of medicines had been further improved. The GPs, pharmacists, or nurses who had prescribing qualifications undertook all medicines changes and reviews, including reconciliation of those that had recently been discharged from hospital. We found all patients on high risk medicines had been appropriately monitored. The practice had engaged with the pharmacy situated next door to the practice to further improve communication and safe working practices.
  • We saw that the practice had systems and processes in place to record and action safety alerts and we found these were well managed.
  • Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines including childhood immunisations and these were well managed.
  • The practice stored securely and had a system in place for tracking the use of prescription stationery throughout the practice.
  • The practice evidenced that there were systems in place to provide clinical supervision of all staff that provide care to patients at the practice.

Effective

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement for providing effective services.

  • The practice had employed regular locum GPs, two pharmacists, two practice nurses, and an advanced nurse practitioner who provided regular sessions.
  • Practice staff had the skills, knowledge, and experience to deliver effective care and treatment.
  • The practice assessed needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. The practice had systems in place to keep all clinical staff up to date. Staff had access to guidelines from NICE and used this information to deliver care and treatment that met patients’ needs.
  • The clinical and management team had regular meetings to manage the performance of the practice in relation to the quality and outcomes framework. The practice overall performance for the Quality and Outcomes Framework (QOF) in 2016/17 was 87% compared to the CCG average of 96% and the national average of 95%. The practice performance for the previous year 2015/16 was 96%. The exception reporting rate for 2016/17 had significantly reduced to 5% which was 6% below the clinical commissioning group (CCG) average and 5% below the national average.
  • The practice had a programme of audits to monitor and encourage quality improvement.
  • The practice engaged in multidisciplinary team working; we saw minutes from meetings attended by a health visitor and palliative care meeting where vulnerable patients had been discussed.

Caring

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement for providing caring services.

  • Results from the National GP Patient Survey published July 2017 showed the practice had improved in some areas of caring but satisfaction was lower in others.

  • A staff member had taken a lead role as a carer’s champion. This staff member ensured patients were aware of the support that was available to them and contacted any new carer identified.

  • The practice had identified 64 patients as carers, approximately 0.9% of the practice list and actively managed their register to reflect changes to patient’s circumstances.

  • Information for patients about the services available was easy to understand and accessible.

  • The practice provided, with the support of the patient participation group, community activities such as coffee mornings, a befriender group, a walking to fitness group and educational sessions.

  • We saw staff treated patients with kindness and respect and maintained patient and information confidentiality.

  • Some staff members were able to speak other languages and had helped patients to access care and treatment in a timely way.

Responsive

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement services for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and CCG to secure improvements to services where these were identified.
  • Appointments could be requested by telephone or email as well as by attending the practice. Following a telephone consultation or email request, appointments were booked as clinically indicated.
  • The practice could book appointments for patients who wished to be seen at the GP Hub in Peterborough in the evenings and at weekends.
  • Patients said they found it difficult to make an appointment with a named GP. Data from the GP Patient Survey published July 2017 showed that 33% of patients usually got to see or speak with their preferred GP compared with the CCG average of 58% and national average of 56%.
  • The practice told us urgent appointments were available the same day and telephone consultations were available. However, some patient feedback from patients reflected that they had difficulty in accessing appointments easily and in a timely manner.
  • 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.
  • Prescriptions could be ordered online, in writing, by phone or in person. The practice had introduced the electronic prescription service which means patients were able to collect their medicines directly from a pharmacy without having to go to the practice first.
  • The practice had responded to patient feedback in relation to delays in patients receiving their medicines. One pharmacist we spoke with told us they were leading an action plan to implement systems and processes to improve this.

Well-led

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement for being well led.

  • The practice had a clear vision to deliver high quality care and promote good outcomes for patients. During the two periods of special measures the practice had received support from the Royal College of General Practitioners.

  • There was a leadership structure in place; this had been further strengthened as the practice had been successful in recruiting new staff and had promoted a staff member to take a lead role. However, the practice had not been successful in recruiting further GPs; there was only one permanent GP in post and therefore limited clinical leadership.

  • We saw evidence that the practice had systems and processes in place to provide clinical supervision although not all staff had received face to face peer review but had received email discussion and feedback. All clinical staff we spoke with told us that they found they had appropriate access to supervision from colleagues and locum GPs.

  • We saw that the practice held meetings with all staff and this included the locum clinicians. We saw evidence that virtual meetings held by email exchange had been successful. These exchanges included feedback on consultations and patient complaints.

  • There had been further improvements in the governance and quality systems and processes and these had been embedded.

  • The practice had been working closely with the CCG and was a testing practice actively working on projects such as introducing care navigator, looking at workflow optimisation and productive general practice. The practice had engaged with the local network and was able to book appointments for patients at the local GP Hub.

  • We saw that practice protocols and policies were in place and had been updated to reflect the change in clinical leads. However not all staff found them easy to access.

  • The practice proactively sought feedback from staff and patients, which it planned to act on. The patient participation group was active and engaged with the management team to discuss and support the improvement plans.

Checks on specific services

Older people

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

  • A clinician prioritised requests for home visits and ensured appropriate and timely care for patients.

  • Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis and heart failure, were in line with local and national averages.

  • A staff member had taken a lead role as a carer’s champion. This staff member ensured they were aware of the support that was available to them contacted any new carer identified.

  • The practice provided, with the support of the patient participation group, community activities such as coffee mornings, a befriender group, a walking to fitness group and educational sessions.

People with long term conditions

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • A lead GP and some nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2016/17 showed that performance for diabetes related indicators was 57%, which was 34% below the local average and the national average. Exception reporting for diabetes in all related indicators was below the local and national averages. The practice had not been able to provide sufficient nursing capacity to meet all the appointments needed in 2016/17. However, we saw evidence that the practice had employed a lead locum GP to undertake reviews and to train the newly employed nursing team. Practice performance for work completed so far in 2017/18 was showing signs of improvement.
  • Data showed that the practice performance for chronic obstructive pulmonary disease (COPD) was 87% compared to the local average of 97% and the national average of 96%. The practice exception reporting was lower than the local and national averages.
  • Patients with long term conditions who were housebound were visited and reviewed by a GP.
  • Longer appointments and home visits were available when needed.
  • Patients with complex needs had a named GP and a structured annual review to check their health and medicines needs were being met. There was a recall system in place to ensure that patients were invited and attended annual reviews.
  • Patients were able to have their blood pressure checked without having to make an appointment first.

Families, children and young people

Requires improvement

Updated 7 December 2017

The practice is rated requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • 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 high for all standard childhood immunisations.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
  • The percentage of women aged 25-64 whose notes recorded that a cervical screening test had been performed in the preceding five years was 82%, which was in line with the local CCG and the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies. We had received some negative feedback from patients who reported that they had not been offered appropriate and timely appointments.
  • We saw positive examples of joint working with midwives, health visitors, and school nurses.

Working age people (including those recently retired and students)

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • 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 where possible.

  • The practice offered extended hours on week days and every Saturday morning.

  • The practice could book appointments for patients who wished to be seen at the local GP Hub in Peterborough.

  • The practice offered online services as well as a full range of health promotion and screening that reflected the needs for this age group.

  • The practice offered an electronic prescription service, which meant that patients would be able to collect their medicines from the pharmacy of their choice with visiting the practice first.

  • Smoking cessation advice and support was available at the practice.

People whose circumstances may make them vulnerable

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

  • The practice worked with other health care professionals in the case management of vulnerable patients, and held regular multidisciplinary team meetings.

  • 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.

  • The practice, with the support of the PPG, offered a befriender service for those who were socially isolated.

  • The practice worked with the community team and held drug dependency clinics.

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 7 December 2017

The practice is rated as requires improvement. The concerns which led to these ratings apply to everyone using the practice including this group.

  • All patients diagnosed with dementia had received an invitation to a face to face care review since April 2017.
  • The practice performance for indicators relating to mental health was 68%; this was 26% below the CCG average and 25% below the national average. The exception reporting for this indicator was 0%. The practice was aware of this data and had an action plan to improve this.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.in addition the practice offered a befriender service.
  • Practice staff had a good understanding of how to support patients with mental health needs and dementia.
  • The practice had information relating to dementia in several different languages.