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Archived: Daneshouse Medical Centre Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 8 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Daneshouse Medical Centre on 5 April 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 systems and processes were not appropriately embedded to keep them safe. For example, patients did not have access to appropriately trained chaperones.

  • Staff were not clear about reporting incidents, near misses and concerns and there was limited evidence of learning and consistent communication with staff. We found numerous examples of incidents that had not been recognised as significant events.

  • Patient outcomes were lower than local and national averages and there was limited evidence of audits or quality improvement.

  • Patients we spoke with were positive about their interactions with staff and said they were treated with compassion and dignity. However, results from the national GP patient survey showed patients rated the practice lower than others for many aspects of care.

  • The appointment systems were not effective, with long waits to be seen, so patients did not receive timely care.

  • The practice did not have a system in place to effectively manage any complaints received.

  • The governance arrangements in place were insufficient to ensure quality care was delivered. Staff were not always fully aware of their roles and responsibilities.

  • Policy guidance was inconsistent, with duplicate polices and guidance available which did not always reflect current best practice.

The areas where the provider must make improvements are:

  • Introduce reliable processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

  • Implement an appropriate system for logging and auditing the location of blank hand written prescription pads.

  • Introduce systems for effectively identifying, recording and managing risks and implementing mitigating actions.

  • Ensure the policies and guidance available to staff to support them in their roles accurately reflect the work undertaken in the practice and are up to date.

  • Establish a comprehensive governance framework so as to allow the practice to effectively assess, monitor and improve the quality and safety of the services provided.

  • Establish an accessible system for identifying, receiving, recording, handling and monitoring complaints.

The areas where the provider should make improvement are:

  • Ensure all documentation relating to pre-employment checks, including interview notes, are maintained appropriately.
  • Consider a more systematic approach to the managerial oversight of staff training.
  • Consider implementing a planned programme of clinical audit to ensure completion of full audit cycles so that quality improvement is proactively monitored.
  • Consider the use of alerts on the patient record system to notify staff if a patient is also a carer.
  • Links should be re-established with the PPG to facilitate further collection of patient feedback. Staff feedback should also be proactively sought.
  • Consider more frequent engagement with locality multidisciplinary team meetings.
  • Review the appointment and telephone systems to ensure that patients are able to access appointments in a timely manner.
  • The business continuity plan should contain more comprehensive information, such as emergency contact details for staff to facilitate the cascade of information.

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

Inspection areas

Safe

Inadequate

Updated 8 June 2017

The practice is rated as inadequate for providing safe services and improvements must be made.

  • The practice did not have an effective system in place for the identification and analysis of significant events (SEs). A number of SEs had not been recognised as such, meaning the practice was unable to effectively monitor trends. In two of the three SEs we reviewed, the practice was unable to evidence that identified action points had been completed or learning disseminated to the staff.

  • The GP safeguarding lead had not received training to the appropriate level at the time of our inspection visit, although this was completed following our inspection. We noted the local authority safeguarding contact numbers contained in practice policies were not current.

  • Blank prescription forms and pads were securely stored, however there was no system in place to monitor the location and use of handwritten forms.

  • An infection prevention and control audit had been completed the week prior to our inspection by a non-clinical member of staff. However, this did not evidence that action was taken, or that an action plan was in place to address any improvements identified as a result.

  • Risks to staff and patients were not effectively identified or monitored. A legionella risk assessment had not been completed at the time of our inspection and the gas safety check for the premises was six months overdue.

  • Chaperone availability was limited and not all staff who acted as chaperone had been trained for the role.

  • Electrical equipment had not been tested to ensure it was safe to use, and although most clinical equipment had been calibrated to ensure it was functioning correctly, some had been missed.

  • While recruitment processes were generally thorough, we did note interview notes were not always held on record.

Effective

Inadequate

Updated 8 June 2017

The practice is rated as inadequate for providing effective services, as there are areas where improvements must be made.

  • Data showed patient outcomes were low compared to the national average. The practice was a negative outlier for a number of QOF clinical indicators from its 2015/16 results. However, we were shown data from the 2016/17 QOF results that was yet to be independently verified that demonstrated improvements in performance.

  • Staff were aware of current evidence based guidance.

  • Staff had the skills and knowledge to deliver care and treatment, and the practice could demonstrate that role specific training had been completed by clinical staff.

  • While staff had access to appropriate training, we observed limited managerial oversight of training to monitor its timely completion.

  • There was limited evidence that audit was driving improvement in patient outcomes.

  • Multi-disciplinary working was taking place; the practice invited the health visitor to attend staff meetings. However, the GP had only attended two locality multidisciplinary team meetings in the previous 12 months.

  • All practice staff had been recruited within the previous 12 months and so had not had an appraisal. However, we noted that performance reviews following completion of their probationary period had not been undertaken either.

Caring

Requires improvement

Updated 8 June 2017

The practice is rated as requires improvement for providing caring services, as there are areas where improvements must be made.

  • Data from the national GP patient survey showed patients rated the practice lower than others for many aspects of care.

  • The patients we spoke to during our visit said they were treated with compassion, dignity and respect and felt cared for, supported and listened to. However, this was not reflected in the results of the GP patient survey.

  • Information for patients about the services available was accessible.

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

  • While the practice identified patients who were also carers, alerts were not used in the electronic patient records to maximise opportunities to signpost them to relevant help and support.

  • Patients told us that access to female clinicians was limited.

Responsive

Inadequate

Updated 8 June 2017

The practice is rated as inadequate for providing responsive services and improvements must be made.

  • Patients reported considerable difficulty in accessing appointments with a clinician and getting through to the practice by telephone. This resulted in high accident and emergency attendance rates at the local hospital for the practice’s patients.

  • Appointment systems were not working well so patients did not receive timely care when they needed it. At the time of our inspection there were no routine pre-bookable appointments available to patients.

  • There was information to help patients understand the complaints process, but this was not readily available to them.

  • There was no systematic approach to the management of complaints. Staff found it difficult to locate documentation relating to complaints that had been lodged, and responses were not always provided within published timeframes.

  • There was no evidence that learning from complaints had been shared with staff.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice had forged a relationship with the neighbouring charity hostel for homeless people, and had a small number of its service users registered as patients.

Well-led

Inadequate

Updated 8 June 2017

The practice is rated as inadequate for being well-led and improvements must be made.

  • The practice did not have a clear vision and strategy. Staff were not always fully aware of their roles and responsibilities.

  • While there was a clear leadership structure in place, staff did not always feel supported by management.

  • The practice had a number of policies and procedures to govern activity, but these were duplicated and inconsistent. Some contained out of date or inappropriate information. The practice did not consistently follow processes documented in policies and procedures.

  • The practice did hold regular staff meetings, but these were not consistently used to communicate key information, such as learning from significant events or complaints.

  • The practice had not proactively sought feedback from staff. When patient feedback had been obtained there had been a limited response to address concerns raised.

  • The practice did not have an active patient participation group.

Checks on specific services

Older people

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of older people.

  • The GP did not routinely attend multidisciplinary meetings to discuss those patients with complex needs or those approaching the end of life.

However:

  • Patients over the age of 75 years were offered an annual review appointment to ensure their health needs were being met.

  • Home visits and urgent appointments for those with enhanced needs were offered when required.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

People with long term conditions

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of people with long-term conditions.

  • Patient outcomes for those with long term conditions were consistently lower than local and national averages.

However:

  • Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met.

Families, children and young people

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of families, children and young people.

  • Immunisation rates were low for standard childhood immunisations.

However:

  • Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice worked with midwives, health visitors and school nurses to support this population group.

Working age people (including those recently retired and students)

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of working age people (including those recently retired and students). However:

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People whose circumstances may make them vulnerable

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

  • The practice could not demonstrate how it regularly worked with other health care professionals in the case management of vulnerable patients.

However:

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

  • The practice had six patients registered who were service users at the neighbouring charity hostel for homeless people.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing and documentation of safeguarding concerns.

People experiencing poor mental health (including people with dementia)

Inadequate

Updated 8 June 2017

The provider was rated as inadequate for safety, effectiveness, responsiveness and for well-led and requires improvement for caring. The issues identified as requiring improvement overall affected all patients including this population group. The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

  • Patient outcomes for those experiencing poor mental health were lower than local and national averages for many clinical indicators.

However:

  • The percentage of patients diagnosed with dementia whose care had been reviewed in a face to face review in the preceding 12 months was 100% compared to the local average of 85% and national average of 84%.

  • Patients at risk of dementia were identified and offered an assessment.

  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.