Archived: Jubilee Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jubilee Health Centre on 9 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. We also carried out enforcement actions which required the practice to provide a report outlining what actions they were going to take to meet legal requirements’.

On the 22 May 2017 we carried out a focused follow up inspection to check whether the practice had carried out their plans’ to meet the legal requirements’ as set out in the enforcement actions which detailed breaches in regulations identified in our January 2017 inspection.

The full comprehensive report on the January 2017 inspection and focused follow up report on the 22 May 2017 inspection can be found by selecting the ‘all reports’ link for Jubilee Health Centre 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 26 September 2017. Overall the practice continues to be rated as inadequate.

Our key findings were as follows:

• The practice did not operate an effective recall or checking process for patient’s prescribed high-risk medicines to ensure prescribing was in line with best practice guidelines for safe prescribing.
• Consultation notes were not comprehensive, there were missed opportunities to assess patients who were over using their medicines and care plans lacked detail.

• Systems were in place for reporting and recording significant events. Individual staff were able to explain learning from incidents; however, documents we viewed did not show evidence of shared learning or actions taken in response to safety incidents.

• The practice operated a system to ensure vaccinations in clinical rooms were within their expiry dates. However, a system for monitoring the content of the GP’s bag was not established and we found an out of date medicine.

• The practice demonstrated compliance with relevant patient safety alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA). However, were unable to demonstrate systems to ensure compliance with local alerts.

• Data from the latest published Quality and Outcomes Framework showed variations in patient outcomes compared to the national average. Unverified data provided by the practice showed progression in achieving 2016/17 QOF targets.

• The practice was able to demonstrate how they had used clinical audits in some areas to improve outcomes for patients and the quality of the service provided. However, systems for monitoring whether actions aimed at achieving quality improvement had been carried out were not established.

• Data from the July 2017 national GP patient survey showed patients satisfaction in some areas had declined since our previous inspection. Staff was aware of survey results and made changes in some areas to improve patient satisfaction.
• Care Quality Commission comment cards we received as part of our inspection showed patients felt they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. However, some comments highlighted difficulties in making appointments.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• The practice had a leadership structure and staff felt supported by management. However, we found the leadership structure lacked ownership or joint approach to address gaps where improvements where needed. There were areas where governance arrangements were not established, effectively operated or implemented. For example, the practice did not operate effective systems to monitor whether relevant nationally recognised guidance were being followed.

There were 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. In particular, management of medicines, ensuring relevant nationally recognised guidance are implemented and followed to reflect best practice to improve patients care and treatment.

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

In addition the provider should:

• Continue to encourage patients to attend national screening programmes such as breast cancer screening.

• Continue to monitor and ensure ongoing improvement to patient satisfaction in line with local and national averages.

• Ensure effective methods are established for sharing learning from incidents.

• Establish a system for distributing local safety communication with relevant staff within the practice.

• Establish a system for monitoring the content of GPs bag and ensure medicines are within manufacturers’ expiry date.

This service was placed in special measures in January 2017 Insufficient improvements have been made such that there remains a rating of inadequate for providing safe and well-led services. 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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jubilee Health Centre on 9 January 2017. The overall rating for the practice was Inadequate. Breaches of legal requirements were found and after the comprehensive inspection we issued the following warning notices:

• A warning notice informing the practice that they were failing to comply with relevant requirements of the Health and Social Care Act 2008. As a result, the practice were required to become compliant with specific areas of Regulation 12: safe care and treatment HSCA (RA) Regulations 2014, by 19 May 2017.

The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Jubilee Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 9 January 2017. This report only covers our findings in relation to those requirements.

Our key findings were as follows:

• System for receiving and acting on alerts from the Medical and Healthcare products Regulatory Agency (MHRA) had been improved.

• There were improvements in the management of medicines which required closer monitoring. We saw some evidence of actions taken to ensure medicines were prescribed within recommended guidelines.

The practice had implemented an action plan to address the areas identified in the warning notice. It was evident that action had been taken to address and improve patient outcomes. However, required actions were ongoing, but not yet completed. As a result, the areas where the provider must make improvement are:

• The provider should continue to implement improvements to the management of medicines within the practice, including monitoring of systems in place to ensure effectiveness.

• Further strengthen systems for managing medical device alerts and medicines alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) and ensure appropriate actions are carried out in line with patient safety recommendations.

This service was placed in special measures in April 2017 and is due to be inspected again within six months of the publication of the final report. When we re-inspect, we will also look at whether further progress has been made to enable compliance with Regulation 12: safe care and treatment HSCA (RA) Regulations 2014; including specific areas for improvement such as management of safety alerts and medicines management.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jubilee Health Centre on 9 January 2017. Overall, the practice is rated as inadequate.

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

• Patients were at risk of harm because some systems and processes were not well embedded or operated effectively. For example, the practice had not gained assurance that appropriate recruitment checks for locum staff had been undertaken prior to their employment. Vaccination expiry dates were not being monitored; and systems for managing patient safety alerts and alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) were not effectively managed.

• In the absence of specific emergency medicines, the practice did not carry out a documented risk assessment to assess how staff would respond to certain medical emergencies. Following the inspection the practice provided evidence of guidelines which staff were required to follow when responding to medical emergencies.

• The process for managing high risk medicines, which require closer monitoring, did not ensure patients were seen within recommended timeframes. There was no clear audit trail to demonstrate that requests for repeat medicines were approved by a clinician.

• Following the inspection, we requested specific information relating to medicine management. The practice response showed further gaps in the management of medicines, which require closer monitoring.

• Staff were clear about reporting incidents, near misses and concerns and there was evidence of learning and actions taken as a result of incidents.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, there were areas where documentation did not demonstrate where staff had assessed patients’ needs and delivered care in line with current evidence based guidance. For example, there were incomplete care templates for some medical conditions.

• Data from the Quality and Outcomes Framework (QOF) showed variations in patient outcomes compared to the local and national average with a high exception reporting rate in some clinical areas. (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). The practice was unable to demonstrate how they had used clinical audits to improve outcomes for patients and the quality of the service provided.

• Care Quality Commission comment cards we received as part of the inspection showed that patients felt that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Comments also highlighted the ease of making appointments with a named GP and there was continuity of care.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Although there was a leadership structure and staff felt supported by management there were areas where governance arrangements were not established, effectively operated or implemented. For example; the practice did not operate effective systems to enable staff to manage risks, ensure relevant nationally recognised guidance were being followed or establish a coherent approach to addressing the quality and performance of specific clinical areas. Although the practice had a system for monthly infection control audits, we saw that the practice were not effectively following their process. For example, the last audit had been carried out in May 2016.

The areas where the provider must make improvement are:

• Implement an effective system to ensure compliance with patient safety alerts and medicines alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
• Establish and operate effective procedures to ensure that appropriate recruitment checks have been carried out prior to commencement of employment.
• Ensure that in the absence of some emergency medicines risks are identified, assessed and formal plans established to mitigate risks associated with anticipated emergencies.
• Establish effective systems and processes to identify; monitor and respond to areas of performance where the practice is performing below local and national averages.
• The practice must establish effective systems to ensure the appropriate monitoring of patients in receipt of high-risk medicines is being carried out as part of, and align with, patients care and treatment plans and ensure clear demonstration of clinical oversight when adding medicines to patient records.
• Ensure the proper and safe management of vaccinations to ensure stock levels remain within manufacturers’ expiry date.
• Ensure relevant nationally recognised guidance is implemented to reflect best practice and improve patients care and treatment.
• Establish and implement effective systems and processes. For example, establish an effective process for handling repeat medicine requests, implement systems for monitoring PGDs to ensure they remain valid, establish an effective system to monitor and improve the quality and safety of services provided.

The areas where the provider should make improvement are:

• Ensure that audits such as infection control are carried out in line with the practice policy and procedures.

• Gain assurance that appropriate fire protection arrangements are in place.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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 a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice