The Care Quality Commission
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  • GP practice

Archived: The Practice Hangleton Manor

Overall: Inadequate read more about inspection ratings

92-98 Northease Drive, Hove, East Sussex, BN3 8LH (01273) 419628

Provided and run by:
Chilvers & McCrea Limited

All Inspections

26 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

The Practice Hangleton Manor was inspected in September 2015 where they were rated inadequate in safe, effective, caring and well-led services. They were rated as good in responsive. As a result the practice was placed into special measures and a warning notice was issued. In February 2016 we carried out a focussed inspection of the areas covered by the warning notice and found that this had not been met. The warning notice was re-issued and was subject to written representations at the time of the announced comprehensive inspection at The Practice Hangleton Manor on 26 April 2016. Overall the practice is rated as inadequate.

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

  • The practice was going through a period of uncertainty due to giving notice on their NHS England contract and this had resulted in some staff resigning from their posts at a time when the practice was experiencing difficulties with recruitment.
  • There was no clear vision, strategy or business plan. However, The Practice Group/Chilvers and McCrea had developed an exit plan for the end of June following NHS England being given contractual notice. The practice were increasingly dependent on locum staff who were not given additional time to undertake activities such as care planning and attendance at practice meetings, despite taking a clinical lead on a day to day basis.
  • The governance systems within the practice did not cover all aspects of clinical activity and not all risks had been properly evaluated and mitigated. For example, monitoring of blood results was undertaken remotely by the lead locum but there were no formal arrangements in place for this and there was no central system evident for how the practice should deal with national guidance and safety alerts.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, locum staff did not have access to the reporting system and were not always involved in discussions and learning from incidents.
  • Risks to patients were assessed and well managed, with the exception of those relating to medicines management.
  • Published data showed patient outcomes were low compared to the national average, although we saw that the practice had worked to improve these for 2015/16.
  • Patients with conditions such as dementia and those with a learning disability were not routinely receiving annual reviews..
  • The practice had worked hard to set up multi-disciplinary meetings for patients at the end of life and those who were vulnerable. However, this had not yet happened and alternative ways to meet other than face to face had not been realised.
  • Clinical audits had been carried out, including evidence of a full cycle audit being used to drive improvements to patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect. However, results from the GP patient survey were low in comparison to local and national figures. For example, in relation to explaining tests and treatments and involvement in care planning.
  • The practice demonstrated some good work around the support they offered for carers and had carried out audits of this to ensure they were meeting carer’s needs.
  • We saw evidence of improved processes around the handling of complaints and acting on feedback from patients. For example, by using audit as a tool to monitor and ensure improvements.
  • The practice had significantly changed their appointment system to increase the number of face to face appointments. This had been a concern identified in previous inspections and through negative patient feedback around the previous telephone triage system.

The areas where the provider must make improvements are:

  • Monitor and assess risks associated with the current staffing issues to ensure that increased risks are adequately mitigated regarding support for locum staff to ensure that safety is not compromised in relation to limited clinical leadership within the practice.
  • Ensure that there is a central system for dissemination of national guidance and safety alerts that provides assurance that this guidance and alerts are being adhered to.
  • Ensure that there is a formal system for monitoring of test results and clinical correspondence that is not dependant on an individual locum GP.
  • Ensure that privacy and confidentiality are maintained in relation to the handling of telephone calls and patient information at the reception desk.
  • Ensure that temperature monitoring of the vaccination fridge is carried out in line with national guidance and the practice policy, that patient group directions are signed by all locum nurses administering them and that competency has been assessed and that prescriptions are securely locked away and adequately tracked within the practice.
  • Ensure that emergency medicines and oxygen with appropriate masks are easily accessible to all staff and that there is a system in place to monitor this during a time when the practice is dependent on locum staff.
  • Ensure that all patients requiring regular reviews of their health have these available to them, that all patients on a chronic disease register have a care plan in place and that regular multi-disciplinary meetings are held for patients at the end of life and for those who are vulnerable.
  • Ensure that information from the national GP patient survey is acted on and used to improve practice and that alongside improvements in care planning patients are involved in planning their care.
  • Ensure that the risks associated with the uncertain future of the practice are fully identified, assessed and mitigated and that close monitoring and reporting to the appropriate external bodies is undertaken.

This service was placed in special measures in December 2015. Insufficient improvements have been made and there remains a rating of inadequate for all the population groups, two key questions and overall. Therefore, the practice continues to be in special measures. On 15 July 2016 this practice was closed by the provider.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

23 February 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of The Practice Hangleton Manor on 23 February 2016.

We had previously carried out a comprehensive inspection of The Practice Hangleton Manor on 8 September 2015. Breaches of regulations were found and the practice was required to make improvements. Following the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulations. We undertook this focused inspection on 23 February 2016 to check that the provider had followed their action plan and to confirm that they now met the regulations in relation to good governance.

This report only covers our findings in relation to those requirements. A further comprehensive inspection will be undertaken to follow up the remaining breaches of regulations and to check that improvements have been made. At this stage the overall rating for the practice will remain unchanged. You can read the report from our last comprehensive inspection by selecting the 'all reports' link on our website at www.cqc.org.uk

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

  • The practice had made some improvements to governance arrangements but continued to have a lack of effective systems to assess, monitor and improve the quality and safety of services provided.

  • There was a lack of processes for sharing the outcome of audit findings and the learning from complaints and significant events, in order to ensure continuous improvement.

  • There was no permanent GP employed within the practice and a lack of clearly defined clinical leadership within the practice on a day to day basis.

  • There was an over-reliance upon telephone triage consultations in place of face to face consultations with patients. The practice had not adequately assessed the impact or potential risk of the appointment system.

  • Multi-disciplinary meetings with other health care professionals were not held within the practice. The practice had not recently held a meeting to review patients receiving end of life care.

  • There was a lack of documented care planning for patients with complex needs.

  • Patient recall systems had been reviewed and improved but were restricted due to a lack of nurse appointments.

  • The practice had established their own virtual PPG and had conducted a survey to gather feedback from patients.

The areas where the provider must make improvements are:

  • Ensure clearly defined clinical leadership within the practice on a day to day basis, including areas of responsibility and allocation of tasks for locum GPs.

  • Ensure processes for sharing the outcome of audit findings in order to ensure continuous improvement.

  • Ensure that learning and changes to processes as a result of significant event analysis and complaints management are clearly recorded and shared with staff to ensure continuous improvement within the practice.

  • Ensure that risks to patients’ health are appropriately managed and that there are systems and adequate resources in place to support patient recall, review and care planning.

  • Ensure multidisciplinary meetings are in place in order to review the care of all vulnerable patients and those receiving palliative care.

  • Ensure that the practice appointment system is adequately risk assessed and subject to regular quality review.

  • Ensure there is a robust plan and clear lines of responsibility in place to implement improvements to patient treatment outcomes, including action planning and review.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

8 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Practice Hangleton Manor on 8 September 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective and caring services and for being well led. It was also inadequate for providing services for all of the population groups. Improvements were also required for providing responsive services.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example the practice did not have a clear system in place for identifying children at risk. Risks to patients in relation to referral and appointment systems had not been adequately considered.
  • Risks to patient’s health were not always managed.
  • Staff were clear about reporting incidents, near misses and concerns and there was evidence of investigation, however learning and communication with staff was not consistently apparent.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example QOF performance data was significantly lower for the practice than the clinical commissioning group (CCG) or national averages. Reviews of chronic disease management were undertaken in an opportunistic rather than planned way, and there were no comprehensive plans in place to address poor patient outcomes.
  • There was no comprehensive system in place to recall and review patients.
  • There were no multidisciplinary meetings held to discuss vulnerable patients. Palliative care meetings had begun to take place although the practice had not adequately identified patients who were nearing the end of life.
  • The practice did not have a clear system in place for sharing information with ambulance or Out-of-Hours services for patients with complex needs.
  • The practice had a plan for nurse-led health promotion campaigns for the year and had demonstrated success in identifying people at risk of dementia and providing appropriate health checks for these patients.
  • Nursing staff participated in meetings with other nurses working within The Practice group/Chilvers and McCrea Brighton based practices. We saw evidence that these meetings included discussions around service planning and training with an emphasis on better meeting the needs of patients.
  • Patients we spoke with were positive about their interactions with staff and said they were treated with compassion and dignity. However there was evidence from other feedback sources that this was not consistently the case. It was unclear how the practice had responded to this feedback.
  • Patient feedback about consultations with nursing staff were positive, with the practice scoring above average in terms of nursing staff giving patients enough time and involving them in decisions about their care.
  • The practice did not undertake a patient survey and it was unclear how feedback from the Friends and Family test and national GP patient survey was used to improve services for patients. The practice was involved in a multi-site practice patient participation group but there was no evidence of how this influenced changes within the practice.
  • Patient privacy and dignity was not sufficiently considered in relation to the environment.
  • Urgent appointments were usually available on the day they were requested, however these were mostly telephone consultations. Patients said that they sometimes had to wait a long time to receive a call back from the GP and information for patients regarding the appointment system was unclear. Patients could not book non-urgent appointments without having had a telephone consultation with the GP first.
  • There was a lack of leadership capacity within the practice to make the required changes to improve patient outcomes and experience.
  • Systems used to monitor the quality of the practice were inconsistent and not being used effectively to improve the service.
  • There were insufficient action plans to improve patient outcomes or satisfaction.
  • The approach to performance, quality and risk was inconsistent.
  • The practice had undertaken 79% of health checks for eligible patients aged 40 – 75.
  • There were effective medicines management and infection control processes in place within the practice.

The areas where the provider must make improvements are:

  • Ensure audits of practice are undertaken, including completed clinical audit cycles.
  • Ensure that safeguarding processes include a clear system for identifying children and adults at risk.
  • Ensure that the practice referral system is adequately risk assessed and subject to regular quality review.
  • Ensure that significant event analysis and complaints management is undertaken in a planned, formal process that involves all relevant staff and is subject to formal review.
  • Ensure that risks to patient’s health are appropriately managed and that there is a robust system in place for patient recall, review and care planning.
  • Ensure there is a robust plan in place for improvements to patient outcomes, including clear prioritisation, action planning and review.
  • Ensure multidisciplinary meetings are in place for discussions of the care of all patients who are vulnerable.
  • Ensure patients who are nearing the end of life are identified and added to the palliative care register.
  • Ensure that the practice clarifies the system for sharing information with the ambulance and out of hours service for patients with complex needs, ensuring that all relevant staff are aware of the system.
  • Ensure that the practice appointment system is adequately risk assessed and subject to regular quality review.
  • Ensure that patient feedback and input from the patient participation group is used to improve practice and develop the service.
  • Ensure that patient’s privacy and dignity is maintained and that processes to ensure confidentiality are in place.
  • Ensure that practice clarifies leadership structure and ensures there is leadership capacity to deliver all improvements.

The areas where the provider should make improvements are:

  • Improve information available to patients on the website and in the waiting area about accessing appointments.
  • Ensure all staff are up to date on their mandatory training.
  • Ensure the practice has a process in place for providing support and follow up to patients who have been bereaved.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice