Archived: West End Surgery

Updated 4 April 2018

West End Surgery is a GP practice within NHS Nottingham West Clinical Commissioning Group’s area. It provides primary medical services to approximately 3,580 patients via a general medical services (GMS) contract. The list size has showed a continual decline over recent years, and the list size has reduced by 40% (approximately 2,500 patients) since 2013. There has been a decrease of almost a further 100 patients since our inspection in October 2017.

West End Partnership registered with the CQC as the provider of this service on 25 August 2017. Although this was a new registration as a partnership, the practice had been operating under the same managerial arrangements since August 2016. The previous registration was with a single-handed GP, and this GP was part of the new partnership which registered with CQC in August 2017. On 2 February 2018, the same GP was removed from the partnership registered with the CQC, leaving two GP partners.

One of the two partners does not work at the practice. The other partner is assigned as the clinical lead and provides some input at the practice. This is mostly in a clinical leadership capacity with no booked clinical sessions, although this GP occasionally sees a few patients. The two GP partners are part of the IMH Group, which manages a network of primary care sites across the country.

The partnership contracts IMH, a multi-speciality care provider to provide the practice’s support services including finance, recruitment, and information technology. Responsibility for compliance with legal requirements is retained by the partnership as the provider registered with the CQC.

The practice is located close to Beeston town centre on the outskirts of Nottingham and is easily accessible by public transport, including the tram which runs directly in front of the building. The premises are within an old converted three floor town house property, which has been sold by the provider and the space is rented back to them. There is limited car parking available on site, but patients can park in an adjacent local car park.

The practice age profile demonstrates lower numbers of younger people compared to local and national averages, and higher numbers of patients aged over 65 compared to national averages, but in line with local averages. The patients are predominantly white British at approximately 90% of those who are registered with the practice.

The clinical team comprises a part-time female GP who plans to work as a salaried GP at the practice from March 2018, two salaried GPs (one full-time male GP, and one part-time female GP), and one part-time female healthcare assistant. A new practice nurse commenced their role at the practice in October 2017, following a period of several months without a dedicated practice nurse. The clinical team is supported by an assistant practice manager. A reception manager heads a team of five reception staff, and there are also two medical secretaries. A CCG pharmacist is based in the practice for two and a half days each week, although due to changes in central funding, the input was reducing to one and a half days each week from April 2018.

The practice manager is identified as the registered manager, although they predominantly work at a different practice managed by the IMH Group. This is the 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. The registered manager was not at work on the day of our inspection and we did not know when they would be returning to work. The provider has submitted a notification form to the CQC about this and identified a named contact for any correspondence in the registered manager’s absence.

The practice opens between 8am and 6.30pm Monday to Friday. GP consulting times are variable but are generally from 8.50am to 11.10am each morning and from 3pm to 5.20pm each afternoon.

Updated 4 April 2018

We carried out an unannounced comprehensive inspection at West End Surgery on 2 and 13 October 2017. The overall rating for the practice was inadequate, and it was placed into special measures. In addition, conditions were imposed on the partnership’s registration with the Care Quality Commission (CQC) in response to the identified breaches in regulations. The conditions were: to strengthen the daily operational management of the practice with an experienced, competent and accessible person who was not a member of the partnership; to appoint a named clinical lead with defined responsibilities; to ensure that all employed staff were appropriately trained for the roles they performed; and to provide an updated action plan to the CQC each month to provide assurance on the appropriate oversight and delivery of safe care and treatment.

The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for West End Surgery on our website at www.cqc.org.uk.

The overall rating of inadequate and special measures status will remain unchanged until we undertake a full comprehensive inspection of the practice within six months of the publication date of the October 2017 report.

We carried out this unannounced focused inspection on 6 February 2018 to confirm that the practice was progressing required actions to meet the legal requirements in relation to the regulatory breaches. The inspection was unannounced due to concerns about the practice which had been received by the CQC.

Our key findings were as follows:

• We found that when significant events had been raised that they were not always investigated and there was a lack of openness and transparency.
• Further to clinical concerns that had been raised within the practice, we reviewed a random selection of recent patient consultations. These records provided evidence of poor record keeping with absent or limited evidence of patient examinations; treatment which was not in accordance with current guidelines; and referral for further investigations where this was deemed to be appropriate.
• The practice had not acted upon areas of identified poor clinical performance.
• Clinical leadership was not evident. We did not see evidence that the identified lead GP was driving clinical improvements within the practice.
• We observed that evidence of follow up actions to alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA) was not always available.
• On the day of our inspection, we found a newly appointed assistant practice manager on their second working day at the practice with no other management representative available on site for support. There was no written evidence to support their induction, but we were told that this had been done verbally the previous day.
• GPs were not up to date with some of the training required for their role. This had impacted on some of their duties, for example, a GP was unable to fit intrauterine devices (coils) as they were not up to date with their basic life support training.
• The practice had made minimal progress in developing working relationships with neighbouring practices since our previous inspection in October 2017.
• The practice performance on the Quality and Outcomes Framework (QOF) had declined from the last two years with performance on the day of our inspection standing at 66% overall achievement, with the year-end outcomes due to be calculated on 31 March 2018.
• Two child safeguarding meetings had taken place in the last 12 months. We found there was some confusion about practice registers to monitor children who were deemed to be at potential risk of harm.
• The practice list size had continued to decrease since our inspection in October 2017.
• The practice was repeatedly identified as being the lowest performing within their CCG. For example, QOF and cervical screening data was significantly below local averages.
• The longer-term sustainability of GP cover within the practice was unclear.
• The practice had addressed many of the site and environmental concerns we identified at our previous inspection. The site had been redecorated and the piles of discarded equipment and documents had been removed from the practice.

Importantly, the provider must make improvements to the following areas of practice:

• Ensure care and treatment is provided in a safe way to patients. For example, by ensuring patient records are complete and accurate, and include a record of any assessment or tests; the treatment that was provided; and details of any investigations or onward referrals undertaken.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, by ensuring that when concerns are reported, these must be documented and investigated. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• The absence of any designated and regular practice nurse input at the practice since April 2017 had meant that long-term conditions reviews had been overseen by GPs.
• There was no clear call and recall system in operation. This meant that patients with more than one condition would be seen at separate reviews of individual conditions.
• The CCG employed pharmacist working at the practice ensured that medicines reviews were undertaken as required with patients.
• Services such as spirometry (a test to assess lung function) and ECGs were offered on site. However, we raised concerns with regards to the oversight of spirometry and the practice agreed to suspend this service until effective governance arrangements were in place.
• For those patients with the most complex needs, the practice team worked with relevant health and care professionals such as the community matron and district nurses, to deliver a multidisciplinary package of care. The practice liaised with specialist nurses and teams to provide expert advice when this was indicated. 

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• The practice could not evidence that staff had received relevant safeguarding training although staff mostly had a sufficient understanding of safeguarding procedures.
• No safeguarding meetings had taken place since February 2017, following a reconfiguration of health visiting teams locally. There were plans to get these formally reinstated with the school nurse.
• Childhood vaccination rates had been below local averages for standard childhood immunisations. Our inspection highlighted that the recall system for children was not working effectively.

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• Older patients had an allocated named GP responsible for their care, although some patients said that they rarely saw the named GP.

• The needs of older people were met through urgent appointments and home visits where these were required.
• Monthly multi-disciplinary meetings were held with community based health professionals to ensure the needs of the most vulnerable patients were being met.
• Routine monthly visits were scheduled at two local care homes where older patients were residents. Urgent requests were responded to on the same day. Each of the homes had a named GP for continuity.

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• Of the 27 returned patient questionnaires we provided during our inspection on 2 October 2017, 70% of patients said that appointments did not run to time with delays reported of up to an hour. People who were working said this created difficulties for them.
• Extended hours surgeries were not provided. There were no early morning appointments available and the first appointment with a GP was usually at 8.50am. The last GP appointment was usually at 5.20pm.
• The practice had a number of telephone consultations each day and some patients told us that they had found this service to be beneficial.

• The practice offered online services including online appointment booking and the ordering of repeat prescriptions.
• The practice participated in the electronic prescription scheme, so that patients could collect their medicines from their preferred pharmacy without having to collect the prescription from the practice.
• The practice provided contraceptive advice and services, including intra-uterine devices (coils) fittings and removals.
• The practice’s uptake rate for cervical cancer screening was below local and national averages. We did not see any clear evidence that attendance was being actively promoted with female patients. 

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• 84% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, and this was in line with the CCG and national averages. The exception reporting rate for this indicator was also in alignment with local and national averages.
• Performance for mental health related indicators was 72% which was 25% below the CCG average and 22% below the national average. Performance had decreased from a 100% achievement in the previous two years. The exception reporting rate for mental health related indicators was higher than local and national percentages.
• 83% of patients with severe and enduring mental health problems had a comprehensive care plan documented in the preceding 12 months. This was lower than the CCG average of 92%, and above the national average of 90%. Exception reporting for this indicator at 33% was significantly above local (17%) and national (12%) figures.
• Patients experiencing poor mental health were provided with information about how to access various support groups and voluntary organisations. 

Updated 14 December 2017

We rated the practice as inadequate for providing safe, effective, responsive and well-led services, and as good for being caring. The concerns which led to these ratings apply across all the population groups we inspected.

• The practice had identified 0.5% of their registered patients as being carers. There was no evidence that carers were being offered ongoing support, and the practice had not identified a carers’ champion.
• The practice informed us that none of the 18 patients on the learning disability register had received an annual review of their health needs in the last 12 months. This meant the practice could not be assured that the health needs of patients with a learning disability were being met.
• Longer appointments were available for patients with a learning disability and for those who required them.
• Palliative care patients were reviewed with community staff at a monthly meeting to ensure their needs were met.
• Feedback from care home staff was positive regarding the service provided to their residents.