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Inspection Summary


Overall summary & rating

Good

Updated 2 April 2020

We carried out an unannounced focused inspection at The Mew Practice on 12 September 2019 in response to concerns which affected a very small number of patients. We returned to the practice on 3 and 8 October to complete a fully comprehensive inspection.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in Two of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At The Mews Practice services are provided to patients under arrangements made by their employer or an insurance provider with whom the service user holds an insurance policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at The Mews Practice, we were only able to inspect the services which are not arranged for patients by their employers or an insurance provider with whom the patient holds a policy (other than a standard health insurance policy). The Mews Practice also provides regenerative therapies and nutritional support which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The patient liaison manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

As part of our inspection we also asked for CQC comment cards to be completed by patients prior to our inspection. We received 14 comment cards which were all positive about the standard of care received. Patients told us that there were treated professionally in a caring manner.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based research or guidelines.
  • Staff maintained the necessary skills and competence to support the needs of patients.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Appointments were available seven days a week.
  • The practice was proactive in seeking patient feedback and identifying and solving concerns.
  • The service was offered on a membership basis or a private, fee paying basis to adults and children.
  • The culture of the service encouraged candour, openness and honesty.
  • The service did not always ensure the proper and safe management of medicines.
  • The service did not always ensure that information was shared appropriately with patients’ registered GPs.

The areas where the provider

should

make improvements are:

  • Continue to develop clinical audit programme to support improvement.
  • Consider reviewing the labelling of medicines dispensed for patients to ensure they reflect best practice.
  • Review and improve how information is shared with the patients' registered GP.
  • Continue to strengthen procedures for the storage and reconstitution of vaccines.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 2 April 2020

We rated safe as Good

.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse. When we reviewed the safeguarding policy on 3 October 2019 it was out of date however the service took immediate action and the policy was up to date when we reviewed it on 8 October 2019.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. However, we noted that the recording of action plans could be improved.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. If items recommended in national guidance were not kept, there was an appropriate risk assessment to inform this decision.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place.

Information to deliver safe care and treatment

Staff did not always have the information they needed to deliver safe care and treatment to patients.

  • The identity of the individual was verified at each consultation. The doctors had access to the patient’s previous records held by the service, to support continuity of care and treatment.
  • On our first day of inspection, 12 September 2019, we reviewed the records relating to a very small number of patients who were voluntarily being cared for in a residential facility and who attended the service to access GP services. We found that the information held about these patients was not always accurate or sufficient in order to allow safe treatment. On our second day of inspection the service provided evidence they had written to the residential service terminating their agreement to provide services to residents of the facility.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service did not consistently have reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • During our inspection we were not assured that one medicine had been used appropriately. This meant that the medicine administered may not have been effective. When we raised this with the service they started an investigation, the results of which assured us that the service had taken action to contact the two patients concerned and followed guidance from the manufacturer to review these patients to ensure that the medicine had been effective.
  • The service had completed initial medicines reviews to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • The service prescribed Schedule 2 and 3 controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence). They also prescribed schedule 4 and 5 controlled drugs. However, we found aspects of the management of controlled drugs did not follow national guidance. For example, one word rationales were recorded in patient records to explain why prescriptions for controlled drugs for periods longer than 28 days were issued.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. When we inspected on 3 October 2019 we found that patient group directions (PGDs) were not being used appropriately. The member of staff who had administered medicines under PGDs should have administered them under a patient specific direction (PSD). The provider took immediate action to ensure that the member of staff only administered medicines under PSD. When we returned on 8 October 2019 we found that the provider had reviewed their protocols for administering medicines and ensured that staff who administered medicines under PSDs were not working without a GP on the premises.
  • Medicines dispensed by the service were over-labelled with a pre-printed dispensing label. Whilst legally complete, these labels lacked the supplementary labels listed in the British National Formulary. Processes were in place for checking medicines and staff kept accurate records of medicines.
  • There was a system in place to effectively verify patient identity before consultations took place. The provider had risk-assessed the services prescribing formulary. The formulary reflected the local NHS GP formulary including antibiotics for the regulated services they offered, including controlled drugs.
  • We saw evidence that when surgical procedures were carried out the batch numbers of the local anaesthetic used was not recorded in the patient record.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety in the service. For example, on one occasion the transport did not arrive to collect samples to be taken to the pathology laboratory. The service investigated and agreed with the pathology laboratory that should this occur again or if they needed to take samples after the samples had been collected, they could be delivered to the laboratory by the service.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team. 

Effective

Good

Updated 2 April 2020

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care generally in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. In treatments where the provider deviated from NICE guidelines, for example iron deficiency, they used other evidence based guidance. The provider told us that any treatment offered would be fully discussed with the patient, including the benefits, risks, and potential side effects.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. Where a follow up appointment was required this was booked at the time of the initial consultation and staff monitored attendance to ensure that follow up appointments were not missed. We found that this process had not been followed for a small number of patients who were voluntary residents in a local residential facility. When we returned on 3 October 2019 we found that the service had reviewed the process to ensure that in future it would be applied to all patients.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. For example, they identified a lack of feedback from specialists following specialist referrals. This they were following up with the local specialists.
  • The service used information about care and treatment to make improvements by reviewing published literature and working with specialists in their field in areas such as iron deficiency and shockwave therapy.
  • The service had introduced an audit programme, however this was at an early stage and it was too early to see much improvement as a result of completed audits. However, a two-cycle antibiotic prescribing audit had been carried out which demonstrated an improvement in antibiotic prescribing for urinary tract infections in line with NICE guidance.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical Council (GMC) and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, GPs looked for appropriate specialists to refer patients to.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • At our inspection on 12 September 2019 the service did not routinely record details of the patients registered GP. Staff we spoke with told us that they gave the patient a copy of the consultation records and it was the patients responsibility to share this with their own GP. However, on 3 October 2019 we saw evidence of some letters that had been sent to patient’s registered GPs, prior to our inspection on 12 September 2019.
  • When we returned to the practice on 3 October 2019 the service had reviewed their policy and amended their registration form for new patients to include details of the patients registered GP. We also saw evidence that the service had introduced a consent form to be completed at registration to enable the service to share information with the patient’s registered GP. The service told us that they would collect registered GP details from their existing members and that all patients would be asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. When we inspected on 12 September 2019 the service had identified some medicines that were not suitable to be prescribed for particular patients. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. However the provider had not considered the risk if the patient did not give their consent to share information with their GP, or if they were not registered with a GP. When we returned on 3 October 2019 the service had reviewed its policy and told us that they would risk assess treatment where patients refused consent to share their information.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example, care for patients who were experiencing poor mental health was shared with mental health specialists. We found that care for a very small number of patients who were voluntarily staying in a residential facility was not well coordinated between the practice and the residential facility. However when we returned on 3 October 2019 the service had given notice to the residential facility that they would not be providing support in the future.
  • Patient information was shared appropriately for referrals to other services (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified and highlighted to patients.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 2 April 2020

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received.
  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language and a hearing loop was available for patients who used hearing aids.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family or carers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 2 April 2020

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. The provider carried out regular analysis of their patient list and the type of services patients were requesting.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. For example; where possible the service contacted specialists directly to book appointments for patients when a referral was made.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint. The service was a member of the Independent Sector Complaints Adjudication Service (ISCAS) and provided patients with information how to contact ISCAS should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 2 April 2020

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.
  • We found that when problems were identified the provider took rapid and appropriate action to address them.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of incidents and complaints.
  • We found that although there was a system for monitoring safety alerts the practice could not assure themselves that one medicine which was potentially affected by a safety alert had been administered effectively.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Patients were offered the opportunity to provide feedback through a tablet computer after each consultation.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work. We saw evidence that staff were given clear responsibilities and supported in their development. Where staff made suggestions, such as introducing a conference call facility to enable staff who were not on site to dial into meetings, these were trialled and introduced if successful. Clinical staff were supported and encouraged to develop their areas of interest, for example, shockwave therapy for chronic pain relief.