Aston Healthcare Limited

We carried out an announced comprehensive inspection at Aston Healthcare Ltd on 13 and 14 November 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 13, 14 and 15 March 2019.

The practice had made improvements since our last inspection.

• Systems and processes had been put in place to address the requirement notices in relation to providing safe care and treatment, providing competent and well-supervised staff and medicines management.
• Action had been taken in response to requirement notices regarding the provider’s leadership capability to deliver high quality care. However, the workflow of the leadership team needs to be reviewed.
• Action had been taken to comply with requirement notices in relation to non-compliance in treating patients with dignity and respect and preserving their privacy; ensuring staff understood the application of the Mental Capacity Act and Deprivation of Liberty Safeguards and receiving and dealing with complaints.

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 have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• Incidents were not always well managed as some staff did not understand that these needed to be reported centrally.
• The processes used to log incidents were unclear.
• Investigations at a branch level were not always escalated to the provider.
• Learning and outcomes from investigations were not always communicated appropriately.
• Information was not recorded in sufficient detail to help identify trends.

However:

• The practice had some newly introduced systems and processes to keep patients safe which had been reviewed and changes made as required.
• Clinicians and receptionists had been given guidance to identify deteriorating or acutely unwell patients suffering from suspected sepsis.
• The practice had introduced appropriate systems for the safe management of medicines.
• The practice continued to embed newly introduced systems to promote learning and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

• There was a significant backlog in long-term condition health reviews.
• An effective service was not provided in relation to promoting positive outcomes for patients for example health reviews; childhood vaccines and cervical screening.

We rated the practice as requires improvement for providing caring services because:

• Verified feedback through NHS England patients survey and information returned through the CQC comment cards identified patient dissatisfaction with most aspects of the service.

However:

• Unverified data from the Friends and Family test result and Healthwatch Knowsley indicated staff were kind to patients and treated them with kindness and respect.

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

• Workforce issues meant processes for learning and continuous improvement were not fully implemented and the leaders could not demonstrate the capacity to provide the presence needed to promote sustained improvements.
• The means by which the senior management team would achieve their goals were not clear.
• The overall governance arrangements had not been in use long enough to allow for their effectiveness to be reviewed.
• Although improvements were found in most aspects of risk management, the practice still did not have clear and effective processes for managing all aspects of running the six surgeries centrally.
• The incident reporting policy and procedures in place needed strengthening.

However:

• Leaders could show that they had the skills to deliver high quality, sustainable care.
• Systems in place to monitor the quality of the clinical service were robust as the provider could offer assurance that clinical data collected was complete and accurate.
• The practice demonstrated a positive culture and had systems in place to collaborate with a variety of stakeholders.

These areas affected all population groups so we rated all population groups overall as requires improvement.

We rated the practice as good for providing responsive services because:

• The effectiveness of the new telephone system needed to be monitored.

However:

• The practice organised and delivered services to meet patients’ needs.
• Patients could access care and treatment in a timely way.
• The provider responded to feedback from stakeholders and was seen to take appropriate steps and make changes promptly in response to feedback.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Take account of staff recruitment; professional qualifications; ongoing indemnity insurance and staff immunisation status.
• Have regard to a centralised failsafe system for monitoring cervical screening results.
• Introduce regular health checks for patients over 75.
• Consider introducing a standard letter to encourage parents to bring their children for immunisation and identify children who have not been brought for their vaccinations and take steps to encourage their parents to bring them for immunisation.
• Take account of the meningitis vaccine for relevant patients.
• Consider how best to use qualified staff to increase the uptake of cervical screening and baby vaccines.
• Produce records from minutes that always provide useful information about what was discussed.
• Review the processes used by the care navigators with regards consistency in guidance provided to patients.
• Reduce the risk of private conversations being overheard at all the practices but particularly at Manor Farm.
• Review the staff compliment of the care navigation team at busiest times of the day.
• Review the response to patient feedback concerned with the telephone queuing system and the timeliness of repeat prescriptions.

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

We carried out an announced comprehensive inspection at Aston Healthcare Ltd on 13,14 and 15 March 2019 to follow-up on breaches of regulations identified at the previous comprehensive inspection carried out on 2,3 and 4 October 2018.

At the October 2018 inspection the practice was put into special measures, requirement and a warning notice and conditions applied in relation to the practice carrying out their regulated activities. This was because we found:

• The registered provider had not developed an infrastructure that was sophisticated enough to effectively manage a service for 27,317 patients spread over six sites.
• Governance arrangements for recognising and managing risks across all branches were not well established or effective.
• Periodical health and safety checks were not always completed and when these were in place the registered provider had not responded to the recommendations in the reports. We noted that there were serious issues concerned with fire safety at three of the branch surgeries.
• The registered provider had not ensured premises in use were fit for purpose and we found that one of the branch surgeries was unfit for use due to the condition of the premises.
• Systems and processes in place to protect children and adults from abuse needed to be strengthened.
• The registered providers recruitment practices did not always promote the employment of staff suitable for working with vulnerable people.
• Processes for reporting, managing and learning from incidents were not well developed.
• Medicines management needed to improve to ensure medicines were safe to use and administered and prescribed in keeping with the legal requirements.
• Equipment, medicines and arrangements for dealing medical emergencies did not promote the well-being of patients.
• The registered provider did not have oversight of the care and treatment offered to patients; there was no central control over the management, deployment or supervision of staff.
• There was no evidence of formal performance management of GPs at the practice and a robust system of consultation, referral and prescribing audits for GPs and nurse clinicians was not in place.
• The systems to manage complaints required improvement. There was limited evidence to show the practice encouraged and welcomed complaints so that their processes could be improved.
• The practice acted on and learned from external safety events as well as patient and medicine safety alerts however this was not always timely.
• Patient feedback we reviewed indicated that staff treated patients with compassion, kindness, dignity and respect, however processes and systems in place did not always support this.

At this March 2019 inspection we followed up on breaches of regulations identified, warning notices and conditions to registration.

The practice had made improvements since our last inspection.

• Systems and processes had been put in place to address the notices of decisions in relation to providing safe care and treatment, providing competent and well-supervised staff and operating from premises which were safe and fit for purpose.
• Action had been taken to respond appropriately to warning notices in relation to the leadership capacity and capability to deliver high quality care.
• Action had been taken to comply with requirement notices in relation to non-compliance in treating patients with dignity and respect and preserving their privacy; ensuring staff understood the application of the Mental Capacity Act and Deprivation of Liberty Safeguards and receiving and dealing with complaints.
• We found that improvements required in the warning notice and conditions to registration had been achieved and these conditions have been removed from the registration certificate.

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 have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• The practice had newly introduced systems and processes to keep patients safe, although it was too soon to measure their effectiveness and impact.
• Clinicians and receptionists had not been given enough guidance on identifying deteriorating or acutely unwell patients suffering from suspected sepsis. However, they were aware of how to respond to other medical emergencies.
• The practice did not have robust systems in place for the safe management of medicines.
• The practice was embedding newly introduced systems to promote learning and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

• There was monitoring of the outcomes of care and treatment however this was not always based on accurate information in that some figures used relating to the same topics differed depending on the source of information.
• The practice could show that staff had the skills, knowledge and experience to carry out their roles, however systems in place to monitor competency was not well developed.
• Some performance data was below local and national averages and the provider could not demonstrate that this information had been used to review practice.
• The practice did not have a system to monitor whether treatment was always provided with the appropriate consent.

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

• Systems in place to monitor the quality of the service were not robust or effective because the provider could not offer assurance that data collected was complete and accurate.
• Leaders could show that they had the capacity and skills to deliver high quality, sustainable care, however these systems were new and had not been embedded.
• The overall governance arrangements were not embedded.
• While the practice had a clear vision, the strategy had not been ratified and implemented.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice demonstrated a positive culture which was reflected in the attitude of staff and staff satisfaction.
• We saw evidence of systems and processes for learning and continuous improvement however these were not fully tested, and a gap was found in relation to responding to themes identified from complaints.

These areas affected all population groups so we rated all population groups overall as requires improvement.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Consider providing practice nurses with level three child protection and adult safeguarding training.
• Review the cleaning schedule to include small hand-held equipment.
• Review the storage of liquids throughout the organisation.
• Review how themes in complaints can be used to improve practice.
• Review how complaints made by patients to stakeholders can be monitored.

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