Archived: Crossroads Medical Practice

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – requires improvement

Are services caring? – requires improvement

Are services responsive? – requires improvement

Are services well-led? - Good

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

Older People – requires improvement

People with long-term conditions – requires improvement

Families, children and young people – requires improvement

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

People whose circumstances may make them vulnerable – requires improvement

People experiencing poor mental health (including people with dementia) – requires improvement.

We carried out an announced comprehensive inspection at Crossroads Medical Practice in September 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. On 7 July 2016 we carried out an announced comprehensive inspection to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings in September 2015. The full comprehensive reports on the September 2015 and July 2016 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

An inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 9 March 2017. Overall the practice was rated as inadequate as insufficient improvements had been made. We carried out an announced focussed inspection of Crossroads Medical Practice on 17 May 2017. This was to check compliance relating to the serious concerns found during the comprehensive inspection on 9 March 2017 which resulted in conditions being imposed on the registration and a notice of proposal to cancel the practice registration was served. We found at that inspection sufficient improvements had been made in relation to breaches of Regulation 12 (Safe care and Treatment) and Regulation 17 (Good Governance). We therefore withdrew the notice of proposal to cancel the service and the practice remained in special measures.

This inspection on 7 November 2017 carried out following the third period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

At this inspection we found:

• Significant improvements had been made since the inspection in March 2017.

• Patients were no longer at risk of harm because adequate systems were in place to keep patients safe including those for dealing with high risk medicines and patient safety alerts.

• Management of high risk medicine prescribing had improved and regular audits were completed to ensure effectiveness.

• The practice had regular monthly meetings with the health visitor to enable joint working, discussion and review of children at risk.

• The process for managing patient safety alerts was effective. We saw that searches had been completed and patients contacted where needed. We saw ongoing evidence of repeated searches to check that any new patients were captured if affected by an alert.

• The system to ensure employment checks were carried out was effective. The locum files were organised, structured and had documented evidence of all checks and training required.

• There was a process for disseminating NICE guidance. Clinical meetings included discussion of NICE guidance in the minutes that we viewed.

• The practice had a plan in place for clinical audit. We saw audits had been completed and were scheduled to have a second cycle. Non clinical audit was in place to evaluate and inform decisions on future staffing and improving patient outcomes.

• Data from the Quality and Outcomes Framework showed patient outcomes were in line with the average for the locality and compared to the national average. However, there had been a decrease in scores from 2015/16 compared with 2016/17. We saw evidence of work to look at ways this would be improved for the future, including recruitment and ensuring the correct skill mix.

• Some of the national patient satisfaction survey results from July 2017 that were below national and CCG averages results had decreased. However scores regarding nurse consultations had improved.

• The practice had reviewed the patient satisfaction survey and had an action plan for work to improve further.

• The practice had developed a triage system for patients which meant that any patient who felt they needed an appointment on the day would be passed to a nurse practitioner or GP who would contact the patient. The clinician would then book an appointment if required. Pre-bookable appointments were available for GPs. However this was one week in advance which was problematic for patients and reception staff when the GP told the patient they should re-book for two weeks time.

• Staff had the skills, knowledge and experience to deliver effective care and treatment although the practice had highlighted that they needed some further knowledge and staff to manage some long term conditions more effectively.

• Information about services and how to complain was available and easy to understand.

• Complaints had been acknowledged and responded to. We saw that learning from complaints was shared as part of the bi-monthly significant event meetings.

• The process for reporting, reviewing and investigating significant events was effective. We saw that there were no outstanding significant events for review and those that had been reported had been actioned, reviewed and lessons learned had been discussed. There were detailed minutes for staff who had been unable to attend the meetings.

The areas where the provider should make improvements are:

• Continue to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, ensuring there are systems in place in order to provide patient care in relation to the monitoring of patient’s health conditions.

• Review the procedure to ensure that fridge temperatures are checked and emergency equipment checks are completed in line with the practice protocol.

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

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 focussed inspection of Crossroads Medical Practice on 17 May 2017. This was to check compliance relating to the serious concerns found during a comprehensive inspection on 9 March 2017 which resulted in conditions been imposed on the registration and a notice of proposal to cancel the practice registration was served. Other areas of non- compliance found during the inspection on 9 March 2017 will be checked by us for compliance at a later date.

The full comprehensive reports on the September 2015, July 2016 and March 2017 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

At this inspection in May 2017, we checked the progress the provider had made to meet the significant areas of concerns as outlined in the conditions imposed and the notice of proposal to cancel registration, for breaches of Regulation 12 (Safe care and Treatment) and Regulation 17 (Good Governance).

Our key findings were as follows:

• We found that all previous significant events that were waiting review had been discussed and reviewed in addition to new events that had been raised.

• The practice had completed reviews of each event and this included learning and actions taken.

• The protocol for managing safety alerts had been reviewed. We looked at the review completed in the practice of all alerts in 2016/17 and looked at searches completed in relation to the ones applicable in primary care.

• All staff had completed the required level of safeguarding training relevant to their role.

• We reviewed records of patients on high risk medicines. We found that the practice had an effective system in place for ongoing monitoring of high risk medicines.

• Shared care protocols (that outlined ways in which the responsibilities for managing the prescribing of a medicine could be shared between the specialist and the practice) were accessible to staff in a folder at reception and a link to these was also on the practice computer system to enable all clinicians’ instant access to them for reference.

• Safeguarding meeting dates had been set for each month of the coming year. One meeting had taken place and there was an agreement in place between the practice and health visitors to have monthly face to face children safeguarding meetings going forward.

• The practice had an effective system in place to ensure employment checks were carried out for all staff including locums.

• We reviewed evidence for disseminating NICE guidance. Clinical meetings had NICE guidance on the agenda and in the minutes that we viewed.

• The practice had a plan in place for clinical audit. At this inspection we viewed a number of audits that had commenced some of which were linked to NICE guidance. One in relation to patients on warfarin showed quality improvement.

• Pre-bookable appointments were available for GPs and nurse practitioners had been recruited and provided appointments and undertook triage of patients.

• Extended hours pre-bookable appointments were available four days per week.

• The practice had implemented a review of complaints similar to the significant events which looked at any learning or changes to practice and included reflection by the staff member involved when appropriate.

• We found that overall leadership had improved. Since the inspection in March 2017 the practice had a new staff structure in place. A new GP had commenced and taken on the role of clinical lead and two nurse practitioners were in post.

The other key lines of enquiry will be reassessed by us at another inspection when the provider has had sufficient time to meet the outstanding issues. At that time a new rating will be assessed for the provider.

The issues that the practice should address are:

• Continue to embed systems in place to improve safety for patients.

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 Crossroads Medical Practice in September 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. On 7 July 2016 we carried out an announced comprehensive inspection to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings in September 2015. The full comprehensive reports on the September 2015 and July 2016 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 9 March 2017. Overall the practice is rated as inadequate.

Our key findings were as follows:

• Patients were at risk of harm because inadequate systems were in place to keep patients safe including those for dealing with high risk medicines and patient safety alerts.

• There had been no improvement in the management of high risk drug prescribing.

• The system for safeguarding children had been strengthened and the practice had reviewed the clinical coding so they could identify those children at risk. However, there had been no consistent discussions to review these patients.

• The process for managing patient safety alerts was not effective. There was no evidence of searches being carried out to identify if the alerts were applicable and no evidence of action taken. We looked for five alerts that that had been issued related to primary care in 2016/17 and found one in the folder. The other four alerts had not been received.

• Some risks to patients who used services were assessed and identified actions had now been implemented. However, the practice did not have an effective system in place to ensure employment checks were carried out for all staff including locums.

• We found no evidence of a process for disseminating NICE guidance. Clinical meetings did not have NICE guidance on the agenda or in the minutes that we viewed.

• The practice had a plan in place for clinical audit. However this plan had not been adhered to and there was no evidence of quality improvement.

• Data from the Quality and Outcomes Framework showed patient outcomes were in line with the average for the locality and compared to the national average. However, we saw examples of patients not coded correctly for their diagnosis. This meant that these patients would not be included in the QOF for that area and patients would not be invited for any reviews that were necessary.

• Some of the national patient satisfaction survey results from July 2016 were below national and CCG averages results. For example

  • 72% of patients were satisfied with the surgery's opening hours CCG average of 78% and national average of 76%.

  • 43% of patients usually get to see or speak to their preferred GP CCG average of 61% and national average of 59%.

• The practice did not have enough appointments available on a daily basis. There were no pre-bookable appointments for GPs.

• Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Information about services and how to complain was available and easy to understand.

• Complaints had been acknowledged and responded to. However, we were still unable to see evidence of sharing the learning of complaints, or any discussion or analysis at meetings.

• The process of identifying patients at high risk of admission to hospital which had commenced in July 2016 was still not complete.

• The process for reporting significant events had improved but the system for reviewing and investigating was not effective as we saw 20 significant events that had been completed that were not reviewed, actioned or discussed.

Importantly, the provider must:

• Ensure patients receive safe care and treatment to include the proper and safe management of high risk medicines.

• Ensure that an accurate, complete and contemporaneous record is maintained for every patient to include a record of the care and treatment provided to them and of decisions taken in relation to the care and treatment provided

• Ensure that the risks to patient health, safety and welfare are assessed, monitored and managed, taking into account the most up to date evidence based guidance such as through the use of MHRA alerts.

• Ensure effective systems are in place to ensure that care and treatment is delivered to patients in a safe way by using the significant events, incidents, near misses and complaints to continually evaluate and improve.

• Ensure effective systems are in place that enables the provider to assess, monitor and improve the quality of the clinical care services provided. Assess whether clinicians have the up to date clinical information available to them and mitigating any such risks identified such as implementing a system of effective clinical audits.

• Ensure there is an effective and consistent system for employment checks to be carried out for all staff including locums.

• Ensure people working at the service receive the appropriate training to carry out their role.

• Use the feedback from the national GP survey to evaluate and improve services.

This service was placed in special measures in September 2015. Insufficient improvements have been made such that there remains a rating of inadequate for safe and well-led. 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. Conditions were imposed on 13 March 2017.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice