The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Mark Stevens Also known as Mapperley Park Medical Centre

Overall: Inadequate read more about inspection ratings

Malvern House, 41 Mapperley Road, Mapperley Park, Nottingham, Nottinghamshire, NG3 5AQ (0115) 841 2022

Provided and run by:
Dr Mark Stevens

All Inspections

20 to 21 March and 10 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at Mapperley Park Medical Centre on 20 and 21 March and an unannounced visit on 10 April 2019. The provider knew we were coming on 20 March but they were not available to speak with us, so we returned the next day to complete the inspection. Following our visit on 20 and 21 March, we received information of concern from the CCG, therefore we returned and undertook an unannounced visit on 10 April 2019.

At this inspection, we followed up on breaches of regulations identified at a previous inspection on 27 July 2018 which was rated as requires improvement overall. We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We previously inspected Dr Mark Stevens (the provider) on the following dates as part of the comprehensive inspection programme:

  • 13 and 14 March 2015 – The practice was rated inadequate overall and placed into special measures for a period of six months.

  • 1 December 2015 – The practice was inadequate overall and remained in special measures as it had not achieved compliance with the regulations.

  • 2 June 2016 – A focussed inspection was undertaken in response to information of concern indicating the provider was not meeting the conditions of its registration. The rating of inadequate still applied.

  • 1 September 2016 – The practice was rated inadequate overall and urgent action was taken to suspend the provider’s registration for a period of three months. This was to allow the provider sufficient time to make improvements.

  • We visited the practice on 1 December 2016 and found no reason to extend the suspension. Therefore, the suspension ceased on 7 December 2016.

  • 25 April 2017 – The practice was rated inadequate overall and remained in special measures as it had not made sufficient improvement to achieve compliance with the regulations.

  • 3, 7 and 22 November 2017 – The practice was still rated inadequate overall and remained in special measures. The CQC acted to prevent the provider from operating the service in line with enforcement policy. The provider appealed against this action to the Health and Social Care first tier tribunal and a hearing was scheduled for 7 to 9 August 2018.

  • 27 July 2018 –The practice was rated requires improvement and one key question remained inadequate, therefore the practice continued to be in special measures.

  • Following the inspection on 27 July 2018 and prior to the tribunal hearing listed for 7 to 9 August 2018, a consent order was made. This agreed that the provider’s appeal was allowed, and that the scheduled hearing was to be vacated and that the following conditions would be added to their registration with the CQC. These are the conditions that the provider must:

  • Ensure that the regulated activities are managed by an individual who is a registered manager inspection of each activity at or from all location.

  • Ensure that the practice has suitably qualified, competent, skilled and experienced person to manage the day to day operations to ensure delivery of the service and that suitable arrangements are made in their absence in relation to their duties.

  • Ensure that an application for a suitable individual to be registered as a Registered Manager is submitted to the CQC by 31 August 2018.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected

  • information from our ongoing monitoring of data about services and

  • information from the provider, patients, the public and other organisations.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.

  • Receptionists had not been given formal guidance on identifying deteriorating or acutely unwell patients.

  • The practice did not always learn and make improvements when things went wrong.

  • Alerts to identify patients who were a safeguarding concern were not always correctly added to their records.

  • It was not clear from the minutes of safeguarding meetings what had been discussed and what action had been taken.

  • Recruitment and induction processes were not always followed, therefore opportunities to minimise unsuitable staff from working with patients was missed.

  • There was no oversight or governance checks to ensure new patient records had been correctly summarised and that coding added to patients’ records were accurate.

  • The practice was not signed to up receive all alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA), therefore these were not always acted upon.

We rated the practice as inadequate for providing effective services because:

  • We saw that the GP had access to NICE and local guidelines and attended a GP update annually. However, care and treatment were not always provided in line with those guidelines and the rationale for this was not clear.

  • Patient consultation notes did not always adequately record the patient’s symptoms and examination to enable a clear understanding of why a particular treatment was or was not offered.

  • Patients at risk of pre-diabetes and diabetes were not adequately followed up or diagnosed with the condition, which meant they were not referred for specialist screening in order to minimise the risk of developing complications associated with the condition.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as inadequate for providing well-led services because:

  • While the practice had made some improvements since our inspection on 15 January 2018, it had not appropriately addressed the Requirement Notices and further concerns were found.

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.

  • While the practice had a clear vision, however that vision was not supported by a credible strategy.

  • The overall governance arrangements were ineffective.

  • The practice did not have clear and effective processes for managing risks, issues and performance.

  • The practice did not always act on appropriate and accurate information.

  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as good for providing caring and responsive services.

This service has been in special measures since March 2015. The practice is now rated inadequate therefore, the practice will remain in special measures.

Since this inspection took place, the provider has applied to cancel their registration and as they will retire on 30 June 2019. Until this time, the service will be kept under review and if needed could be escalated to further urgent enforcement action.

Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to cancel the provider’s registration.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27/07/2018

During a routine inspection

This practice is rated as requires improvement (Previous rating November 2017 – Inadequate)

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

We carried out an announced comprehensive inspection at Dr Mark Stevens (Mapperley Park Medical Centre) on 27 July 2018.

Dr Mark Stevens (the provider) has been inspected previously on the following dates:

  • 13 and 14 March 2015 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months.

  • 1 December 2015 – The practice was rated inadequate overall and remained in special measures as it had not made the required improvements to achieve compliance with the regulations.

  • 2 June 2016 – A focused inspection was undertaken in response to information of concern indicating the provider was not meeting the conditions of its registration. The overall rating of inadequate still applied.

  • 1 September 2016 – The practice was rated as inadequate overall and urgent action was taken to suspend the provider’s registration for a period of three months.

  • We visited the practice on 1 December 2016 and found no reason to extend the suspension. Therefore, the suspension ceased on 7 December 2016.

  • 25 April 2017 - The practice was rated inadequate overall and remained in special measures as it had not made sufficient improvements to achieve compliance with the regulations.

  • 3,7 and 22 November 2017 – The practice was still rated inadequate and remained in special measures. The CQC also acted in line with our enforcement procedures to begin the process of preventing the provider from operating the service. The provider appealed against this action to the Health and Social Care first tier tribunal.

  • This inspection was undertaken following the continued period of special measures and was an announced comprehensive inspection on 27 July 2018.

  • Following this inspection and prior to the scheduled tribunal hearing a consent order was made by the tribunal which stated that the hearing listed for 7-9 August 2018 would be vacated and the provider’s appeal was allowed on the agreement of conditions being added to their registration with CQC as a service provider. These conditions are that the provider must:

  • Ensure that the regulated activities are managed by an individual who is registered as a Manager in respect of each activity at or from all locations.

  • Ensure that the practice has a suitably qualified, competent, skilled and experienced person to manage day to day operations to ensure delivery of the service and that suitable arrangements are made in their absence in relation to their duties.

  • Ensure that an application for a suitable individual to be registered as a Registered Manager is submitted to the CQC by 31 August 2018.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Dr Mark Stevens on our website at www.cqc.org.uk.

At this inspection we found:

  • The system for dealing with significant events had improved and staff understood their responsibilities to raise concerns and report incidents. These were discussed with relevant staff on a regular basis, learning identified and acted upon.

  • Although improvements had been made to the systems relating to safeguarding, further improvement was required as the safeguarding register was not being reviewed appropriately to ensure relevant children were identified and discussed at meetings.

  • Alerts received from the Medicines and Healthcare Products Regulatory Agency (MHRA) were acted upon.

  • There were now arrangements in place to assess, manage and review risks.

  • Examples we found during our inspection identified a theme that patient records were not always updated appropriately or with sufficient detail following the receipt of incoming information to the practice.

  • Improvements had been made but there was still not an effective system to manage the summarisation of patient records. Of the 300 patient records which had not been summarised at the time of our last inspection there were still over 150 which were recorded as not having been summarised.

  • Unverified Quality and Outcomes Framework data for 2017-18 showed that exception reporting had improved and was now at an acceptable level demonstrating greater oversight.

  • A new recall system had been introduced in April 2018 for patients with long term conditions in need of review. The practice manager had oversight of the system but it still required embedding to ensure its effectiveness.

  • Feedback we received from patients was consistently positive about the staff and said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Patients we spoke with and who gave written feedback expressed their ongoing satisfaction with the appointment system and said they found it easy to make an appointment with the GP and valued their continuity of care.
  • Daily open access appointments were available to patients which meant they could be seen on the same day. Patient feedback reflected that overall, they were happy with the access system.

  • There was a leadership structure in place and since the employment of a full-time practice manager the structure was effective and roles and responsibilities had been clarified.

  • Feedback from staff indicated they felt respected, valued and supported by the GP and the practice manager. All staff were involved in discussions about how to run and develop the practice and were committed to providing a quality service.

The areas where the provider must make improvements as they are in breach of regulations are:

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

  • Ensure patients are protected from abuse and improper treatment.

The areas where the provider should make improvements are:

  • Ensure the induction system for locums is embedded.

  • Ensure the new recall system is embedded.

This service has been in special measures since March 2015. Although improvements have been made there remains a rating of inadequate for providing a safe service. Therefore, the practice will remain in special measures. The service will be kept under review and if needed could be escalated to further urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

3, 7 and 22 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Dr Mark Stevens (the provider) has been inspected previously on the following dates:

  • 14 January 2014, 14 August 2014 and 10 November 2014 using previous inspection methodology which focused on specific outcomes.

  • 13 and 14 March 2015 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months.

  • 1 December 2015 – The practice was rated inadequate overall and remained in special measures as it had not made the required improvements to achieve compliance with the regulations.

  • 2 June 2016 – A focused inspection was undertaken in response to information of concern indicating the provider was not meeting the conditions of its registration. The overall rating of inadequate still applied.

  • 1 September 2016 – The practice was rated as inadequate overall and urgent action was taken to suspend the provider’s registration for a period of three months.

  • We visited the practice on 1 December 2016 and found no reason to extend the suspension. Therefore, the suspension ceased on 7 December 2016.

  • 25 April 2017 - The practice was rated inadequate overall and remained in special measures as it had not made sufficient improvements to achieve compliance with the regulations.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Dr Mark Stevens on our website at www.cqc.org.uk.

This inspection was undertaken following the continued period of special measures and was an announced comprehensive inspection on 3, 7 and 22 November 2017. Overall the practice is still rated as inadequate.

Our key findings were as follows:

  • Staff understood their responsibilities to raise concerns and report incidents. These were discussed with relevant staff on a regular basis. However, further improvement was required in the investigation and analysis of significant events in order to correctly identify appropriate and relevant learning from incidents and to ensure that necessary actions were taken.

  • There was not a consistent system to identify and record safeguarding concerns. Some children were not appropriately identified as being at risk and opportunities to identify potential safeguarding concerns had been missed.

  • Alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA) were acted upon.

  • Some risks to patients were assessed and managed although some had not been reviewed since 2015. Other risks had not been identified.

  • Although the arrangements to manage medicines had improved the system in place to ensure the safe management of vaccines still required further improvement.

  • There was not an effective system to summarise patient records. We found that over 300 patient records had not been summarised and at the time of our inspection there were no staff trained to carry out this task.

  • We identified a number of errors relating to summarising, coding or consultations not being visible on patient records which meant that accurate and up to date information was not always available which put patients at risk.

  • Data showed that patient outcomes were generally in line with local and national averages but there were much higher than average levels of exception reporting in some areas which identified a lack of clinical oversight. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).

  • There was not a consistent and effective recall system in place for patients with long term conditions in need of review. It was not clear who had overall responsibility or oversight of this.

  • Feedback we received from patients reflected positively about the staff and said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • Patients we spoke to and who gave us written feedback expressed high satisfaction with the appointment system and said they found it easy to make an appointment with the GP and that there was continuity of care.
  • Daily open access appointments were available to patients which meant they could be seen on the same day. Patient feedback indicated they did not mind if they had to wait to be seen by the GP as they valued the service highly.

  • There was a leadership structure in place but this was not effective and roles and responsibilities were not always clear.

  • Feedback from staff indicated they felt respected, valued and supported by the GP and the practice manager. All staff were involved in discussions about how to run and develop the practice and were committed to providing a quality service.

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

Importantly, the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. More detail can be found in the enforcement section at the end of this report.

  • Ensure patients are protected from abuse and improper treatment.

More detail can be found in the enforcement section at the end of this report.

In addition the provider should:

  • .Ensure non-clinical staff have training and support relevant to their role, for example relating to administration tasks and management of the cold chain.

This service was placed in special measures in June 2015. Insufficient improvements have been made such that the provider remains inadequate overall. Therefore we are taking 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. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 November 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Following our inspection which took place on 1 September 2016, we took urgent action to suspend Dr Mark Stevens from providing general medical services at Mapperley Park Medical Centre.

We conducted a further announced focused inspection on 30 November 2016 to check whether the provider had made sufficient improvements in respect of being safe and well led and to decide whether the suspension period should be ended.

The ratings remain the same, inadequate overall and that the special measures period continues. We will inspect again to ensure that improvement requirements have been met.

This report covers our findings in relation to our focused inspection of safe and well led. You can read our findings from our last inspections by selecting the ‘all reports’ link for Dr Mark Stevens on our website at www.cqc.org.uk.

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

  • A system had been developed to ensure significant events and patient concerns were monitored in a systematic way to ascertain lessons learnt and to indicate any areas for on-going development.

  • Systems had been established to ensure the practice was receiving national patient safety alerts.

  • A system had been established to ensure contemporaneous patient records were always maintained for every patient consultation.

  • New systems had been implemented to made sure referrals to secondary care were acted upon in a timely manner to ensure co-ordinated care and treatment for patients.
  • Two new part time practice managers had been recruited, along with new reception staff and a practice nurse.

  • During previous inspections we found that accurate and contemporaneous record were not being kept for each patient following consultation. Although we could not test this operationally, at this inspection we found that the provider had further implemented a system that would allow accurate and contemporaneous records to be kept.

  • At our previous inspection we found that nationally available patient safety information including Medicines Health and Regulatory Authority (MHRA) alerts were not always being obtained and followed. At this inspection we found that the provider had ensured that they were registered to receive all patient safety alerts.

  • At our previous inspection we found that the provider did not have an effective system for the review and management of high risk medicines. The provider had reviewed their systems and incorporated improvements.

  • All of the changes implemented can only be assessed once the new methodology has been put into practice – then the appropriateness, workability and sustainability of the new systems and processes can be determined.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Dr Mark Stevens (the provider) has been inspected previously on the following dates:

  • 14 January 2014, 14 August 2014 and 10 November 2014 using previous inspection methodology which focused on specific outcomes.
  • 13 and 14 March 2015 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months.
  • 1 December 2015 – The practice was rated inadequate overall and remained in special measures as it had not made the required improvements to achieve compliance with the regulations.
  • 2 June 2016 – A focussed inspection was undertaken in response to information of concern indicating the provider was not meeting the conditions of its registration. The overall rating of inadequate still applied.
  • 1 September 2016 – The practice was rated as inadequate overall and urgent action was taken to suspend the provider’s registration for a period of three months.
  • We visited the practice on 1 December 2016 and found no reason to extend the suspension. Therefore, the suspension ceased on 7 December 2016.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Dr Mark Stevens on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 25 April 2017. Overall the practice remains rated as inadeqaute.

Our key findings were as follows:

  • There had been significant improvements to the provider’s recording of contemporaneous notes. A review of records demonstrated notes were recorded in a timely manner following patient consultations.
  • Staff understood their responsibilities to raise concerns and report incidents. These were discussed with relevant staff on a regular basis. However, learning was not always identified to ensure events did not reoccur.
  • Systems had been improved to ensure patients being prescribed high risk medicines were appropriately reviewed and monitored.
  • Evidence indicated alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA) were being received and acted upon.
  • Some risks to patients were assessed and managed; however there were areas where risks had not been identified including the risk of not having assessed the competency of the healthcare assistant.
  • Arrangements to manage medicines were not always operated effectively. Systems in place to ensure the safe management of vaccines were not being operated effectively and blank prescriptions were not being tracked in line with guidance.
  • Data showed that patient outcomes were in line with local and national averages and evidence demonstrated the practice had made improvements to the level of care provided to their patients.
  • Patient feedback was consistently and strongly positive about the care and treatment provided by the practice.
  • Open access was provided to patients on a daily basis; patients were positive about being able to access GP appointments on the same day. However, patients often waited a long time to be seen by a GP.
  • There were limited mechanisms in place to enable the practice to record and act upon verbal feedback from patients.
  • There was a clear leadership structure in place but roles and responsibilities were not always clear, for example, in relation to health and safety.
  • Policies and procedures were in place but evidence indicated these were not well embedded and not always followed within the practice.

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

Importantly, the provider must:

  • Ensure significant events and incidents are investigated thoroughly and learning identified including the reporting of events externally where required.
  • Ensure staff providing care and treatment to patients have the competence, skills and experience to do so safety.
  • Ensure the proper and safe management of medicines
  • Ensure systems are operated effectively to assess, monitor and improve the quality and safety of service provided and to identify and assess risks to the health and safety of service users
  • Ensure systems are in place to support obtaining the required pre-employment checks for newly appointed staff.
  • Ensure policies and procedures are followed by staff and embedded within the practice

In addition the provider should:

  • Improve the awareness of staff in relation to safeguarding arrangements
  • Consider the training needs of staff including face to face training
  • Ensure mechanisms are in place to record and act upon verbal feedback
  • Consider auditing patient waiting times and demand for appointments
  • Ensure effective recall systems are in place for patients with long term conditions

This service was placed in special measures in June 2015. The service remains in special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mark Stevens on 1 December 2015 to check that the practice was meeting regulations. Overall the practice is rated as inadequate.

Our previous comprehensive inspection carried out in March 2015 found breaches of legal requirements (regulations) relating to the safe, effective and well led domains; and improvements were required for the responsive domain. In addition, all population groups were rated as inadequate due to the concerns found in safe, effective and well led. The overall rating from the March 2015 inspection was inadequate and the practice was placed into special measures for six months.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements. The inspection carried out on 1 December 2015 found the practice had not made sufficient improvements to comply with three of the regulations they were previously in breach of. These related to safe care and treatment, good governance and fit and proper persons employed.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report significant events.

  • Improvements had been made to the assessment of risks relating to the health, welfare and safety of patients.

  • However, patients were still at risk of harm because effective systems were not in place to ensure identified risks were sufficiently mitigated and their management was embedded. For example: medicines management; risks relating to the environment and service delivery; carrying out of appropriate disclosure and barring checks for all staff undertaking chaperone duties and students working with vulnerable adults and children

  • Clinical staff did not always assess patients’ needs and deliver effective care in line with current evidence based guidance. For example, 56% of medical records we reviewed did not contain an accurate, complete and contemporaneous record in respect of each patient’s consultation. This included a record of the care and treatment provided and of decisions taken in relation to the care and treatment provided.

  • Nationally reported data showed most patient outcomes were below the local and national averages.

  • Improvements had been made to ensure patients were invited for appropriate health reviews and screening programmes.

  • Staff were supported with training, supervision and professional development.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with same day appointments available for both urgent and routine appointments.

  • The practice did not offer online services to patients of working age, students and those recently retired; and the practice website contained very limited and up to date information on available services.

  • The practice had sought feedback from patients and had an active patient participation group (PPG).

  • Limited improvements had been made to ensure sufficient clinical leadership and regular review of governance arrangements.

  • There was a clear leadership structure and most staff felt supported by management.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way. Specifically, operate an effective system that regularly identifies, assesses and manages risks to patient safety; as well as monitors the quality of services provided.

  • Ensure an accurate and contemporaneous record is kept for each patient, with sufficient information in relation to their assessment of needs, planning and delivery of care.

  • Ensure records relating to the management of the service and related policies and procedures are appropriate, kept up to date, shared with relevant staff and implemented in practice.

  • Take action to address identified concerns related to medicines management (recording, prescription handling and patient reviews).

  • Ensure chaperones are subject to a disclosure and barring check or that a risk assessment is in place to address this issue.

  • Ensure all clinicians are kept up to date with national guidelines and effective systems are in place for the provider to be assured these are implemented. This is important to ensure patients receive appropriate care and health reviews.

  • Ensure effective governance, including assurance and auditing processes that drive improvement in the quality and safety of the services provided. This includes both clinical and non-clinical governance arrangements.

The areas where the provider should make improvement are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

  • Continue to pro-actively identify and support carers.

  • Ensure arrangements for receiving and acting on complaints are strengthened.

This service was placed in special measures in June 2015. Insufficient improvements have been made such that there remains an overall rating of inadequate. We took urgent enforcement action and served an Urgent Notice of decision imposing additional conditions on the service provider’s registration in respect of the regulated activities carried out from this location. The below conditions took effect from 7 December 2015 and will remain in force until removed by the Care Quality Commission (the CQC).

  1. New patient registration – Dr Mark Stevens must not register any further patients without the prior written agreement of the Care Quality Commission.

    This is to enable the service provider to focus on securing and sustaining improvements and compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulated Activities Regulations 2014). Further, this condition will protect any further patients from any risks to their health and welfare.

  2. Completion of electronic patient records following consultation - Accurate contemporaneous notes of all patient consultations carried out at the practice must be recorded immediately on patients’ electronic records going forward.

    The inspection found that accurate patient records were not routinely being completed following consultation. This will ensure that necessary and appropriate information is recorded against each patient when they have had a clinical consultation including the outcome of the consultation. This reduces the risk that patients receive inappropriate treatment due to the lack of recording.

  3. D. Mark Stevens must send to the CQC each month an independent report providing assurance that condition 2 has been met.

This is to provide confidence to the CQC that patient records are being adequately and appropriately recorded.

We are also taking 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. The service will be kept under review and if needed could be escalated to further urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice  

1 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Dr Mark Stevens (the provider) has been inspected on the following dates:

  • 14 January 2014, 14 August 2014 and 10 November 2014 based on the former inspection methodology which focused on specific outcomes.

  • 13 and 14 March 2015 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in Special Measures for a period of six months.

  • 1 December 2015 - The practice was rated inadequate overall and remained in Special Measures as it had not made the required improvements to achieve compliance with the regulations.

  • 2 June 2016 – This was a focused inspection in response to information of concern indicating the provider was not meeting the conditions of its registration. The overall rating of inadequate still applied.

    We carried out an announced comprehensive inspection at Dr Mark Stevens on 1 September 2016. Overall the practice is rated as inadequate.

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

  • The system in place for reporting, recording and analysing significant events did not ensure all staff were aware of their responsibilities. We found examples of clinical incidents that had not been analysed in a systematic way to inform any changes that might lead to future improvements.

  • The practice was not receiving all of the available patient safety alerts. Records reviewed showed staff had not taken appropriate action in response to some of the medicine related alerts issued by external agencies.

  • Some patients were at risk of not receiving effective care or treatment. For example, clinical staff did not always assess patients’ needs and deliver effective care in line with current evidence based guidance and contemporaneous patient records were not always maintained for every patient consultation.

  • Referrals to secondary care were not always acted upon in a timely manner to ensure coordinated care and treatment for patients.

  • Although some improvements had been made to the assessment of risks relating to the health, welfare and safety of patients; patients were still at risk of harm because effective systems were not in place or sustained to ensure identified risks were sufficiently mitigated and their management was embedded. For example: medicines management; risks relating to the environment and service delivery.

  • Although nationally reported data showed most patient outcomes were below the local and national averages, 2015/16 data showed improvements had been made in respect of the management of some long terms conditions and uptake rates for health reviews and cancer screening.

  • Clinical audit was used to identify areas of good practice and/or improvement. Most audit cycles were due to be repeated in six to 12 months to measure the improvements made.

  • Improvements had been made to ensure sufficient non-clinical and clinical staff were in post. This included recruiting a part-time GP locum, five reception staff and a part-time practice manager. However, the induction process required improvement to ensure it was comprehensive and that staff were supported with appropriate mentoring and key training at the start of their employment.

  • The practice had sought feedback from patients and had an active patient participation group (PPG). However, on this occasion the PPG had provided limited input to drive service improvement and patient feedback (friends and family test results) had not been analysed to improve service provision.

  • Patient feedback was overwhelmingly positive about the way staff treated people and all patients confirmed they had consistently received patient centred care and felt valued as individuals. The high level of compassion and respect provided was highlighted in the national GP patient survey, comment cards and patients we spoke with to during the inspection. For example, 100% of the respondents to the national survey said the last GP they spoke to was good at treating them with care and concern compared to the local and national averages of 85%. A number of patients gave specific examples of the GP visiting at weekends and evenings to ensure patients received continuity of care and families were supported.

  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with same day appointments available for both urgent and routine appointments.

  • There was a clear leadership structure and staff felt supported by management.

    The areas where the provider must make improvements are:

  • Ensure an accurate and contemporaneous record is kept for each patient, with detailed information in relation to their assessment of needs, planning and delivery of care.

  • Ensure effective systems are in place for care and treatment to be delivered in line with national guidance and best practice guidelines. This is important to ensure patients receive appropriate care and reviews.

  • Maintain records to evidence the receipt of and actions taken in respect of nationally available patient safety information including Medicines and Healthcare products Regulatory Agency (MHRA) alerts to ensure prescribing remains safe.

  • Implement an effective system that ensures improvements are made to the review and management of high risk medicines and essential monitoring required. In addition, all clinicians must work in line with defined shared care guidelines.

  • Maintain up to date records concerning the management of the regulated activities. This includes ensuring practice policies and procedures are appropriate, discussed with staff and implemented in practice.

  • Implement a comprehensive induction process and clear system to monitor the completion of staff training relevant to their roles and responsibilities. This should include assurance that appropriate staff have completed mandatory training.

  • Ensure effective governance, including assurance and auditing processes that drive improvement in the quality and safety of the services is in place. This includes both clinical and non-clinical governance arrangements that identifies, assesses and manages risks to patient safety; as well as monitors the quality of services provided.

  • Ensure there is effective leadership capacity to deliver all improvements including increased practice management support.

    The areas where the provider should make improvement are:

  • Improve arrangements for logging and acting upon concerns received from patients to enable improvements to be made.

  • Improve the practice website to ensure it contains relevant and up to date information and on-line services are provided for patients in line with contractual agreements.

  • Review the meeting frequency and role of the patient participation group to maximise patient feedback in the improvement of services.

Due to the nature of the concerns identified on this inspection, this practice remains in special measures and urgent enforcement action has been taken to protect the safety and welfare of people using this service. The provider’s registration been suspended for a period of three months. Specifically, the carrying out of the following regulated activities: Treatment of Disease and Disorder and Diagnostic and Screening Procedures from Mapperley Park Medical Centre, 41 Mapperley Road, Mapperley Park, Nottingham, Nottinghamshire NG3 5AQ.

The suspension took effect from 12pm on 7 September 2016 until 9am 7 December 2016. The Nottingham City clinical commissioning group and NHS England had plans in place to ensure all risks to patient safety are reviewed. The practice will be inspected again before the final date of suspension to check if insufficient improvements have been made.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out two comprehensive inspections of Dr Mark Stevens’ practice in May 2015 and December 2015. At both inspections we found breaches of legal requirements (regulations) relating to the safe, effective and well led domains; and all population groups were rated as inadequate as a result.

The practice was placed in Special Measures in July 2015. The special measures process is designed to provide a clear timeframe (six months from the publication of the final report) within which providers must improve the quality of care they provide and a framework within which the Care Quality Commission can use enforcement powers to ensure improvements are made or to take further action. The overall rating from the December 2015 inspection was inadequate and the practice remained in special measures.

We carried out an unannounced focused inspection at Dr Mark Stevens on 2 June 2016, in response to information of concern and identified breaches of imposed conditions on the provider’s registration. This inspection cannot change the ratings. There will be a full re-inspection within six months of the inspection report published on 3 March 2016.

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

  • Some improvements had been made to the assessment of risks relating to the health and safety of patients. This included: operating effective recruitment procedures, carrying out disclosure and barring checks for all staff undertaking chaperone duties and students working with vulnerable adults, and suitable arrangements were in place for monitoring the premises and environment.

  • However, patients were still at risk of harm because effective systems were not in place to ensure risks relating to medicines management were sufficiently mitigated and their management was embedded.

  • Information of concern indicated there would be imminent workforce changes which would not ensure sufficient numbers of staff with the right skills and experience were in post, and consistency of care was maintained for patients. For example, all non-clinical staff employed at our December 2015 inspection had submitted their resignations with end dates varying between June and July 2016.

  • Some patients were at risk of not receiving effective care or treatment. For example, clinical staff did not always assess patients’ needs and deliver effective care in line with current evidence based guidance.

  • Information was not always acted upon in a timely manner to ensure coordinated care and treatment for patients.

  • The delivery of high-quality care was not assured by the leadership, governance or culture in place. For example, there were low levels of staff satisfaction and staff felt supported and valued to a degree.

  • The provider is in breach of two of the three urgent conditions imposed on their registration with effect from 7 December 2015. The conditions are:

  1. New patient registration – Dr Mark Stevens must not register any further patients without the prior written agreement of the Care Quality Commission (CQC).

  2. Completion of electronic patient records following consultation - Accurate contemporaneous notes of all patient consultations carried out at the practice must be recorded immediately on patients’ electronic records going forward.

The areas where the provider must make improvements are:

  • Ensure the conditions imposed on the provider’s registration are complied with to protect any further patients from any risks to their health and welfare and to meet legal requirements.

  • Ensure care and treatment is provided in a safe way (medicines management - recording, prescription handling and patient reviews).

  • Ensure effective clinical governance arrangements are in operation to drive improvement in the quality of the services provided.

The areas where the provider should make improvements are:

  • Ensure sufficient staff with the right skills are employed and retained to meet the needs of patients. This includes promoting a positive workplace environment for staff and ensuring they are well supported and valued in their roles.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13 and 14 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mark Stevens (Mapperley Park Medical Centre) on 13 and 14 April 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective and responsive services, and being well led. It was good for providing caring services. The concerns which led to these ratings apply to all population groups using the practice.

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

  • Patients were at risk of harm because systems and processes were not sufficient or robust enough to keep them safe. For example, appropriate recruitment checks on staff had not been undertaken prior to their employment, and actions identified to address concerns with infection control practice had not been completed.
  • Although staff understood their responsibilities to raise concerns, and report incidents and near misses, safety was not sufficiently prioritised and there were inadequate systems in place to record, monitor and manage risks.
  • There were unsuitable arrangements in place to ensure there were sufficient staffing levels and an appropriate skill mix to deliver services and support patients.
  • Staff had not received essential training appropriate to their roles and any further training needs had not been identified and planned.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example, assessment of their care and treatment needs and timely reviews of repeat medicines.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • Same day appointments were usually available on the day they were requested. However patients said that they sometimes had to wait up to two weeks for non-urgent appointments.
  • The practice had insufficient leadership capacity and very limited formal governance arrangements to enable assessment and monitoring of the service and the identification and management of risks.

The areas where the provider must make improvements are:

  • Ensure appropriate action is taken to address identified concerns with infection prevention and control practices to ensure patient and staff safety.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure staff are competent and skilled to perform their roles and responsibilities through the delivery of appropriate training, professional development, and regular supervision.
  • Ensure there are formal governance arrangements in place and staff are aware how these operate. This includes effective systems for assessing and monitoring risks, and the overall quality of service provision.
  • Ensure patient records and records relating to the management of regulated activities are kept securely and fit for purpose. This includes staff having appropriate policies and guidance to carry out their roles.
  • Ensure a statement of purpose is in place and that all staff understands the practice’s vision and their responsibilities in fulfilling this.
  • Ensure the regulated activities are managed by an individual with the appropriate knowledge of applicable legislation including the Health and Social Care Act 20087 (Regulated activities) Regulations 2014 and relevant best practice and guidance.
  • Ensure on-line facilities are available for repeat prescriptions and on-line appointments.

The areas where the provider should make improvement are:

  • Review the processes for making appointments.
  • Review arrangements for involving the practice team in decisions about the delivery of services

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 November 2014

During an inspection looking at part of the service

At our inspection on 10 November 2014, we followed up enforcement action that we had taken following our inspection on 14 August 2014. We found the provider had made improvements in ensuring that suitable arrangements were in place to assess and monitor the quality of service provision. This included the review of patients' health conditions and medicines; and acting upon the recommendations from other health professionals to ensure safe care.

Patients we spoke with were complimentary about the service received and expressed no complaints in relation to the care they had received.

14 August 2014

During an inspection looking at part of the service

All the five people we spoke with were complimentary of the care they had received and felt well informed about decisions relating to their care. One person told us the GP is "a family orientated doctor'. He listens to me and is very caring'. Another person told us "I have nothing but praise for this practice. It's like a small family. I would recommend it to anybody'. We observed staff to be professional and polite when attending to patients and received no complaints from people we spoke with.

We found some improvements had been made to the care and welfare of people using the service. Suitable arrangements were in place to ensure that adequate staffing levels were provided to meet peoples' needs and the management of the service. However, the provider did not have an effective system in place to identify, assess and manage risks relating to the health, welfare and safety of service users.

14 January 2014

During a routine inspection

We spoke with nine patients, five staff, one visiting NHS professional and NHS England who are the commissioners of the service.

Patients told us they were treated with care and respect and we saw positive exchanges between patients and staff. One patient said, 'I have every confidence in the GP, I'm so glad we found him.' Another patient said, 'You're never made to feel like you're wasting his time. He gives you the time you need.'

Patients said their views about their care and treatment were listened to and that it met their needs.

The risk that patients may not always receive safe and appropriate care was increased because there were not enough staff meet the demands of the practice.

Although patients were actively involved in an assessment to identify their needs the systems and processes to manage the service were not always efficiently managed and patient records were not always kept up to date.