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Archived: Midlands Medical Partnership-Lea Village Medical Centre Inadequate

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Inadequate

Updated 5 July 2018

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Midlands Medical Partnership-Lea Village Medical Centre on 4 April 2018 and 19 April 2018. The practice last received a comprehensive inspection under the previous provider on 30 September 2016 and received an overall rating of requires improvement. Prior to this, the practice had been in a period of special measures.

The current provider of this practice registered with CQC in July 2017.

The reason for this inspection was to follow up the concerns identified at our previous inspections of this practice and other concerns that had been identified prior to the new provider registering this practice. The inspection was to ensure the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were being met.

At this inspection we found:

  • The new provider had put in place a range of systems and processes to support the practice in the provision of safe and effective services. However, these were not well embedded and were not followed by all staff at the practice.
  • Risks were not always well managed within the practice and we found weaknesses relating to safeguarding arrangements, infection control, management of medicines, medical emergencies and for acting on incidents and safety alerts.
  • We identified concerns in relation to the quality of care provided and found care and treatment that was not consistent with evidence based guidelines.
  • Evidence seen suggested most staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was mixed feedback from patients with regard to the appointment system, a small proportion of patients reported that they found it difficult to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • Although we saw significant changes had been made to restructure and improve the management of the practice, the governance arrangements that had been put in place had failed to identify and address some of the poor clinical care identified during the inspection and that the provider systems and policies had not been implemented by the local practice.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure patients are protected from abuse and improper treatment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review the cause of delays in post being received and actioned to identify how this may be improved.
  • Consider ways in which the identification of carers could be increased to ensure support is provided.
  • Consider how the effectiveness and patient input into the practice could be improved.
  • Review soundproofing of the main consulting room and how this may be improved.

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 5 July 2018

We rated the practice as inadequate for providing safe services.

Although the provider had put in place systems and processes to support the provision of safe services we found that these were not consistently being followed by all staff at the practice. We found weaknesses relating to safeguarding arrangements, infection control, management of medicines, medical emergencies and for acting on incidents and safety alerts.

Safety systems and processes

The provider had implemented organisational wide systems to keep patients safe and safeguarded from abuse. However, these were not consistently well implemented at this practice.

  • The practice had a nominated safeguarding lead, staff received role relevant safeguarding training and safeguarding policies and procedures were in place. However, the safeguarding lead was unaware of the safeguarding polices in place. We also saw that the safeguarding registers were not regularly reviewed and the practice’s safeguarding lead did not know how to retrieve them and was unaware of the reasons for patients being on the child protection register. There were no patients listed on the vulnerable adults register, although we identified vulnerable adult patients during the inspection that should have been.
  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (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.)
  • The provider had put in place systems and processes to ensure appropriate staff checks were carried out at the time of recruitment and on an ongoing basis.
  • We found the premises visibly clean and tidy and appropriate cleaning arrangements in place. Staff had access to personal protective equipment and infection control training as part of their induction. An infection control audit had been carried out in the last 12 months however, progress and monitoring against the action plan was not evident, we identified actions that had not been completed or followed up.
  • The practice had some arrangements to ensure that facilities and equipment were safe and in good working order. Risk assessments in relation to health and safety had been undertaken including fire and legionella. Weekly health and safety audits were carried out of the premises however we found these did not include risks in relation to liquid nitrogen on the premises. Protective equipment for use in liquid nitrogen was not appropriate.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

The practice had some systems to assess, monitor and manage risks to patient safety however there were weaknesses in the arrangements relating to the management of medical emergencies.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics. As part of a large provider organisation staff were able to work across sites as needed. For example, at the time of inspection the practice did not have a permanent practice nurse. Sessions were covered by an agency nurse with additional support from the lead MMP nurse and specialist MMP nurses. We were advised that a new practice nurse had been recruited and was soon due to start.
  • There was an effective induction system for temporary staff tailored to their role. There was an information pack available for locum GPs. Staff advised us that staff working on a temporary basis were usually shown around by the team leader or one of the administrative team to familiarise them with equipment and procedures.
  • We looked at the arrangements for dealing with medical emergencies and found there were emergency medicines and equipment available and that staff received appropriate training. Checks were undertaken of emergency medicines and equipment however, these had not been effective as records showed one of the medicines had been out of date for several months before being replaced, there was no paediatric oxygen mask. In the absence of one recommended emergency medicine risk had been considered but all risks had not been fully mitigated. A notice in one of the clinical rooms directed staff to the wrong place for the emergency equipment which may cause confusion to temporary or locum staff working in the practice.
  • Evidence seen during the inspection did not provide assurance that all practice staff were fully aware of and understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. We saw that guidance was displayed in the consulting room for early warning of sepsis and a sepsis template had been placed on the clinical system to support clinicians in making an assessment. However, equipment to support clinical assessment of sepsis was not readily available to clinical staff in the consultation rooms. There was a pulse oximeter as part of the emergency equipment but was not available as part of the routine equipment necessary for examinations being undertaken in consulting rooms. Reception staff advised they would report any concerns they had about a patient to a clinician but did not have any specific guidance to help recognise and respond to ‘red flag’ or emergency symptoms they may be presented with.

Information to deliver safe care and treatment

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

  • Our review of patient records identified coding issues with patient information for example, a patient with cancer and a patient with a long term condition that had not been coded. Coding was undertaken by the practice. Accurate coding helps identify patients such as those with long term conditions that need regular follow up. A member of clinical staff had undertaken an audit of their own coding but had not identified any concerns in contrast with our findings.
  • We were advised by staff that post was dealt with and cleared on a daily basis. However, we found delays with information being scanned on to patient records. Letters were not routinely date stamped to show when they had been received.

Appropriate and safe use of medicines

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

  • We found weaknesses in the systems for managing and storing some medicines. We found liquid nitrogen for use in minor surgery stored in the treatment room without appropriate signage, inadequate protective equipment and no risk assessments undertaken. Monthly expiry date check sheets for emergency medicines did not reflect the stock held.
  • We found examples of inappropriate prescribing and examples of poor antimicrobial stewardship.
  • We reviewed prescriptions awaiting collection. There was no evidence that these were being routinely reviewed and acted on in line with the providers prescribing policy. Prescriptions awaiting collection dated back to July 2017.
  • We identified examples where patients’ health in relation to the use of medicines had not been followed up or monitored appropriately. We reviewed ten patients on high risk medicines. We identified concerns with the monitoring checks for six of these patients for example, blood tests that were overdue. High risk medicines require routine monitoring to ensure they are safe to prescribe due to the significant risk of harm or death to a patient if misused or used in error. Routine searches undertaken to identify patients on high risk medicines which required monitoring did not capture all patients such as those on acute prescriptions.

Track record on safety

The practice, under the previous provider registration did not have a good track record on safety. At the request of the local clinical commissioning group the practice was merged with Midlands Medical Partnership (MMP) in April 2018 to support improvements within the practice.

  • Since the merger, MMP had made significant changes to the practice. This included new clinical systems, policies and procedures and managerial support. However, we found these systems and processes were not being effectively followed by all staff at practice level in order to keep patients safe.
  • The centralised team undertook reviews of performance and learning from incidents from across the organisation but was reliant on the local practice team to provide the information for this.

Lessons learned and improvements made

Although there were corporate systems and processes for managing incidents and making improvements when things went wrong, these were not well embedded within the practice.

  • The provider had introduced systems for reviewing and investigating when things went wrong, this took place at a local level. Local incidents were shared with the central management team who reviewed and identified those for wider learning across the whole organisation. Leaders and managers from the central team were available to support the local teams if needed.
  • Most staff we spoke with at the practice understood their duty to raise concerns and report incidents and near misses. However, this was not evident of all staff.
  • The provider shared with us ten significant events that had occurred at the practice during 2017 to 2018. However, not all clinical staff at the practice were able to recall any local incidents that had occurred and any learning outcomes over the last 12 months.
  • The provider had introduced systems for acting on and learning from external safety events as well as patient and medicine safety alerts. Safety alerts were centrally managed and forwarded to the individual practices to act on. We saw the provider had undertaken an audit against a recent medicines safety alert. We saw alerts about risks were placed on the relevant patient records and advice had been given to the patients.
  • We asked staff at the practice if they were aware of any other examples of alerts they had acted on but not all clinical staff were able to recall any.

Please refer to the Evidence Tables for further information.

Effective

Inadequate

Updated 5 July 2018

We rated the practice as inadequate for providing effective services overall and across all population groups.

The practice was rated as inadequate for providing effective services because our review of patient records did not assure us that patients at this practice received quality of care that was in line with evidence based practice.

(Please note: Any Quality Outcomes (QOF) data relating to 2016/17 is published data. This was collected prior to the new provider. Any QOF data referred to after 2016/17 relates to unpublished data. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

The provider had put in place systems to keep clinicians up to date with current evidence-based practice. This included templates for clinical staff to follow which were designed to reflect best practice and the requirements of the quality outcomes framework. We saw that the specialist nurses were using templates when undertaking respiratory and diabetic reviews. They were able to show us how they accessed guidelines from their computers. However, not all clinical staff at the practice were using the templates or knew how to access them.

Our reviews of other patient records found that evidence based guidelines were not being consistently followed by all clinical staff at the practice. We saw examples of clinical records where patients’ needs had not been adequately assessed and appropriate care and treatment provided.

The principal GP advised us they kept up to date with the latest guidance and attended meetings and learning events arranged by the provider.

Older people:

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • The practice provided flu vaccinations for those eligible in this population group.
  • The provider advised us that there were registers in place for those at risk of unplanned admissions and these were followed up on discharge. However, evidence seen from patient records during our inspection did not provide assurance that systems of follow up were operating effectively at the practice.

People with long-term conditions:

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • There was a centralised team that supported the practice in recalling patients with long-term conditions for their annual review, although this was dependent on the accuracy of coding by the practice.
  • The practice had been supported by specialist nurses from the provider organisation to undertake reviews of patients with diabetes and respiratory conditions supporting improved outcomes for these patients.
  • Although we saw that the practice had scored well against the quality outcome framework for long-term conditions our review of patient records did not demonstrate that patients always received appropriate care and treatment for their conditions.

Families, children and young people:

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. The practice was supported by the provider’s centralised recall system to help improve uptake. Data provided by the provider showed uptake rates for the vaccines during 2017/18 given were in line with the target percentage of 90% or above. This was an improvement on the 2016/17 up take rate which was below 90%.
  • The principal GP advised us that they carried out post-natal checks and advice. During our review of records we identified baby checks undertaken with incomplete assessments.
  • During the inspection we identified concerns in relation to the practice’s safeguarding arrangements for children.

Working age people (including those recently retired and students):

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • Data from Public Health England showed the practice’s uptake for cervical screening (2016/17) was 60%, which was below the 80% coverage target for the national screening programme. However, this data was collected prior to the merger with MMP. Following the merger, the provider put in place a centralised recall system and had enlisted the support of their lead nurse to try and improve uptake while a permanent practice nurse was recruited for this practice. Based on QOF data the uptake of cervical screening had increased by 5% between 2016/17 and 2017/18.
  • The most recent data for the practice’s uptake for breast and bowel cancer screening was also below the local and national average. This data was also collected prior to the merger with MMP. The provider told us they were working in partnership with Cancer Research UK in order to improve cancer screening uptake. The impact of this at this practice has yet to be determined.

  • Patients had access to NHS checks for patients aged 40-74.

People whose circumstances make them vulnerable:

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • Since the merger, the provider had worked to improve the palliative care register and introduce a gold standard framework. The palliative care register had increased from 7 to 27 patients. Templates had been put in place to support care planning of end of life care needs but not all clinical staff at the practice were using these. Meetings took place with the palliative care team to discuss the need of patients reaching end of life. However, we reviewed the palliative care register and found no evidence of end of life care plans in place or of discussions having taken place about end of life care needs.
  • Staff were given training in relation to child and adult safeguarding. However, there were no patients listed on the adult safeguarding register, this was despite identifying vulnerable adults during the inspection.
  • The health care assistant had been trained to provide learning disability reviews at the practice. There were 11 patients on the learning disability register and 55% had received an annual review during 2017/18 this was an improvement on the previous year of 44%.
  • The provider had put in place system alerts to identify patients identified with an underlying medical condition that required the pneumonia vaccine. An audit had also been undertaken of patients who were asplenic or hyposplenic (no or reduced function of the spleen leading to reduced immune system) to ensure they received the vaccination. The provider had escalated with NHS England concerns regarding the shortage of this vaccine.
  • Patients at this practice could access substance dependency services provided at other sites within the provider organisation.

People experiencing poor mental health (including people with dementia)

This population group was rated inadequate for effective because our review of patient records did not assure us of the quality of care patients received at this practice.

  • Nationally available data showed that 89% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the previous 12 months. This is comparable to the national average.
  • The provider was working in partnership with the Alzheimer’s Society to provide support to patients with dementia and their families. Staff were also being trained to become dementia friends.
  • Nursing staff we spoke with told us that they had received local training in relation to dementia and that they carried out dementia assessments as part of the NHS health checks to be referred to the GP. However, the principal GP advised us that they did not carry out any specific dementia assessments to identify patients with possible dementia because they would be carried out at the memory clinic.
  • We reviewed records for three out of the eight patients on the dementia register at the practice. None had a care plan in place, despite being coded as done.
  • Nationally available data showed that 90% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This was comparable to the national average.
  • The practice also reported that 100% of patients experiencing poor mental health had received discussion and advice about alcohol consumption. This was above the national average.
  • We saw evidence of mental health reviews having taken place for patients on the mental health register. However, we also identified two cases were patients with poor mental health had not received adequate follow up.

Monitoring care and treatment

Since the merger of Lea Village Medical Practice the provider had undertaken a programme of quality improvement activity. The provider had identified a programme of actions to deliver the quality outcome framework (QOF) programme. This had involved implementing systems for recalling patients for their health reviews, collecting data and routinely monitoring and benchmarking progress of the practice against other practices within the provider organisation. The practice was achieving high scores against QOF targets. End of year QOF performance for 2017/2018 showed the practice had achieved 98%.

The provider also shared with us four completed audits they had undertaken which included two audits relating to the appropriate monitoring of patients on high risk medicines, improvements were seen on re-audit. However, during the inspection our review of high risk medicines identified further work was still needed to ensure all patients received appropriate monitoring.

Despite the systems put in place by the provider our review of records did not indicate that patient care at this practice was consistent with achieving good outcomes for all patients. For example:

  • We reviewed 36 patient consultation records since January 2018, of these there were issues with 19 of the records including inadequate assessment of the patients presenting symptoms or condition, inappropriate prescribing, lack of follow up or safety netting (advice on what to do if symptoms worsen) and coding issues.
  • Minor surgery was carried out at the practice. We identified concerns with this service. There was no effective system for checking histology had been sent or returned for all tissue samples sent to the laboratory. We found no audits had been undertaken to assess the quality of the service.
  • There was also a lack of follow up of patients who did not collect their prescriptions.

Effective staffing

The provider supported staff in developing skills, knowledge and experience to carry out their roles.

  • Following the merger, the provider had brought in their specialist nurses and lead practice nurse to support the practice and carry our reviews of patients with some long term conditions and for general practice nursing duties including immunisations and taking samples for the cervical screening programme. Nursing staff were able to demonstrate how they kept up to date for these roles.
  • 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. All staff were invited to attend education events.
  • We saw evidence of a clear induction process for new staff. Staff received annual appraisals and support and where relevant support for revalidation.
  • We saw that the provider had delivered training to all practice staff in relation to the new clinical systems and processes following the merger. However, not all staff were effectively using the new clinical systems and processes as intended.
  • The provider had a clear approach for supporting and managing administrative staff when their performance was poor or variable and were able to give examples as to how this had been put in place.
  • However, the provider did not have systems to ensure effective oversight of the quality of clinical care provided by all clinical staff or that new processes and systems were being used by all staff.

Coordinating care and treatment

  • Meetings took place with health visitors to discuss vulnerable children and multi-disciplinary team meetings took place for patients with end of life care needs on a quarterly basis.
  • However, we identified issues with patients receiving coordinated and person-centred care. We reviewed patients on the palliative care and dementia registers and found no care plans in place for these patients.
  • The provider told us that they had implemented systems to support the referral process and had provided training but this was not being utilised at the practice.
  • We found referral letters to other services such as secondary care were inadequate to support the safe delivery of care and treatment. Referral letters seen lacked detail, for example, information relating to past medical history, medicines and allergies. The provider told us that they had implemented systems to support the referral process and had provided training but this was not being utilised at the practice. Following the inspection the provider also advised that information such as past medical history, medicines and allergies were automatically transferred as part of the referral process.
  • The provider advised us that they used special notes for sharing information for the out of hours service.
  • The provider was working in partnership with third sector organisations such as the Alzheimer’s Society to provide additional support to patients with dementia and their families.

Helping patients to live healthier lives

  • As part of the wider provider organisation staff at the practice could refer patients to services provided by other practices for example, sexual health and substance misuse services.
  • NHS health checks were carried out to identify patients with additional needs.

Consent to care and treatment

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

  • We saw that consent was recorded for child immunisations and minor surgery.
  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Mental Capacity Act guidelines were displayed in consulting rooms.

Please refer to the Evidence Tables for further information.

Caring

Requires improvement

Updated 5 July 2018

We rated the practice as requires improvement for caring.

The practice was rated as requires improvement for caring because we identified areas for improvement which included taking into account patients individual needs, involving patients in care and treatment and ensuring patients privacy is maintained.

Please note that any data relating to the National GP Patient Survey (published July 2017) was collected prior to the current provider.

Kindness, respect and compassion

Overall staff treated patients with kindness, respect and compassion.

  • Feedback from patients such as the national GP patient survey was collected prior to the merger with Midlands Medical Partnership (MMP) showed some scores in relation to patient consultations that were below the national average. The new provider organisation had identified actions in response which focussed on improving the service patients received.
  • Feedback from the completed CQC comment cards was mostly positive about the service.
  • Evidence seen as part of the inspection indicated that most staff understood patients’ personal, cultural, social and religious needs.

Involvement in decisions about care and treatment

Staff were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.) However, records seen did not always show that patients were always involved in decisions about care and treatment.

  • Staff communicated with people in a way that they could understand. Staff told us that if they needed information in a different format they could ask the central team to provide this.
  • Information was available to help patients and their carers access community and advocacy services. Carers events were running within the wider provider organisation which patients could attend.
  • The practice identified carers and provided information and support. Although the number of carer’s identified was low for the practice size.
  • Results from the latest national GP survey (published in July 2017) showed results for questions about patients’ involvement in care and treatment was significantly worse than national averages. (It should be noted that the survey related to a period prior to the merger). The new provider had developed an action plan to make overall improvements within the practice.
  • During the inspection, our review of patient records found examples where patient did not appear to have been appropriately involved in care and treatment for example in relation to dementia and end of life care.

Privacy and dignity

The practice respected patients’ privacy and dignity although there was room for improvement.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Staff recognised the importance of people’s privacy and dignity. However, one patient commented that conversation in the doctor’s room could be overheard. This had also been noted in the minutes of the patient participation group but had yet to be acted on.

Please refer to the Evidence Tables for further information.

Responsive

Requires improvement

Updated 5 July 2018

We rated the practice, as requires improvement for providing responsive services

.

We rated the practice, and the following population groups: People with long-term conditions; Families, children and young people and People experiencing poor mental health as requires improvement for providing responsive services. People whose circumstances make them vulnerable population group we rated as inadequate and the remaining population groups were rated good.

The practice was rated as requires improvement because: Registers for those who were most vulnerable were not well maintained in order to support those patients. Reviews of records for those with mental health needs and dementia did not indicate needs were always well understood and responded to. Access to services was also raised by a small proportion of patients through complaints and our CQC comment cards.

Responding to and meeting people’s needs

  • The provider was working to improve service provision at the practice to meet the needs of its population for example, through dedicated diabetes and respiratory clinics.
  • The facilities and premises were appropriate for the services delivered although some refurbishment was needed.
  • The practice made reasonable adjustments when patients found it hard to access services.

Older people:

This population group was rated as good for responsive:

  • All patients had a named GP.
  • Home visits were carried out for those who were housebound. This included a home visits for phlebotomy services if needed.
  • The premises were accessible for those with mobility difficulties.
  • There was a hearing loop on site.

People with long-term conditions:

This population group was rated requires improvement for responsive:

  • The provider had implemented systems to recall patients with a long-term conditions to the practice for an annual review to check their health and medicines needs were being appropriately met. However, coding issues identified may have meant some patients were being missed from recall.
  • The practice held regular meetings with the local community nursing team to discuss and manage the needs of patients with complex medical issues.
  • Patients at the practice could access various diagnostic and monitoring services for their long term condition at this and other practices. For example, electrocardiographs, spirometry and 24 hour blood pressure monitoring.

Families, children and young people:

This population group was rated as requires improvement for responsive:

  • All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.
  • The practice offered a breast feeding friendly service if needed.
  • Child safeguarding registers were not kept up to date to effectively meet the needs of those most at risk.

Working age people (including those recently retired and students):

This population group was rated as good for responsive:

  • The practice did not operate any extended opening hours however by arrangement patients could be seen at one of the other MMP practices for their nurse led extended service.
  • The provider offered online services for booking appointments and for repeat prescriptions.

People whose circumstances make them vulnerable:

This population group was rated as inadequte:

  • The provider organisation hosted clinics with the Citizens Advice Bureau across their practices which patients from Lea Village Medical Centre could attend.
  • We reviewed safeguarding registers and found these were not kept up to date. There were no vulnerable adult patients identified by the practice on their register. However, during the inspection we had identified vulnerable patients.
  • We were advised the provider was following the gold standard framework. We reviewed seven records and saw none of the patients had care plans in place.
  • People in vulnerable circumstances were able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

This population group was rated requires improvement for responsive:

  • The provider advised us that staff had been trained to be dementia friends and were working alongside the Alzheimer’s Society to provide additional support for patients with dementia and their families. However, our review of patient records did not indicate that patients mental health and dementia needs were well understood by all clinical staff.

Timely access to care and treatment

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

  • The latest national GP patient survey results showed responses relating to access to appointments was in line with local and national averages. (Please note data collected for this survey was collected prior to the new provider). However, we noticed four complaints and two of our comment cards related to difficulties in obtaining appointments.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients could access on-line services for making appointments and ordering repeat prescriptions.
  • The provider advised us that patients at this practice could attend extended nurse clinics at their other sites.

Listening and learning from concerns and complaints

The provider took complaints and concerns seriously and had put in place systems to oversee the complaints process at the practice and to identify shared learning to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available.
  • The provider had implemented a standard complaint policy and procedures that were consistent with the whole organisation and were in line with recognised guidance.
  • Complaints were investigated at a local level and shared with the provider’s central team.
  • Learning from concerns and complaints were shared across the whole provider organisation.

Please refer to the Evidence Tables for further information.

Well-led

Inadequate

Updated 5 July 2018

We rated the practice as inadequate for providing a well-led service.

The practice was rated as inadequate for well-led. Although there had been significant changes and improvements to the practice’s governance arrangements these arrangements had failed to identify some of the poor clinical care and failure by the practice to embed systems and processes identified during the inspection.

Leadership capacity and capability

The leadership of the provider organisation had the capacity and skills to deliver high-quality, sustainable care. However, a lack of oversight of the clinical care provided at this practice and weaknesses in the local leadership had resulted in areas of poor care left unaddressed.

  • Lea Village Medical Centre merged with Midlands Medical Partnership (MMP) in April 2017. The previous provider had been through a period of special measures, there had also been other concerns raised in relation to the practice.
  • Following the merger, leaders within the new provider organisation undertook an analysis to identify action needed to drive improvement and support the delivery of high quality services. This involved introducing new clinical systems with more capability, templates to support best practice, standardised systems and processes, standardised policies and procedures.
  • The leadership team was visible and approachable. They worked closely with practice staff to implement the new infrastructure and to provide training and support.
  • The centralised team provided managerial support to the practice increasing the leadership capacity and skills available to the practice.
  • However, we found during our inspection that there were concerns with areas of clinical care provided at the practice and oversight of this clinical care had been missed within these arrangements.

Vision and strategy

The provider had implemented a clear vision and credible strategy to deliver high quality, sustainable care which was shared across the whole provider organisation.

  • The vision and values were displayed in the practice. There was a realistic strategy and supporting business plans to achieve priorities set.
  • The provider worked with the CCG to address local health and social priorities. This included participation in the Aspiring for Clinical Excellence programme, a CCG led scheme aimed at driving standards and consistency in primary care and delivering innovation.
  • The provider had introduced positive changes to the practice following the merger as well as introducing a new infrastructure, the provider had increased clinical capacity and provided systems for staff learning and development.
  • However, not all staff at the practice were actively sharing the vision, values and strategy. This was evident in some of the examples of poor clinical care identified and failure to follow some of the systems and processes that had been put in place.

Culture

  • Staff we spoke with stated they felt respected, supported and valued. They were positive about the support provided from the centralised team. They felt able to raise concerns and were confident that these would be addressed.
  • There were processes for providing all staff with the development they needed. Staff had received annual appraisals within the last year and were supported to meet the requirements of professional revalidation where necessary.
  • Regular staff and team meetings took place across all staff groups which enabled staff to share information and support improvement. There were regular learning events which staff were encouraged to attend.
  • However, it was not clear that changes and system improvements delivered had been accepted and implemented by all staff at the practice. Evidence found during the inspection did not demonstrate that the practice always focused on the needs of patients and high quality care.
  • We saw evidence that leaders and managers had acted on behaviour and performance inconsistent with the vision and values of the organisation. The actions in place to support and guide the implementation of MMP processes and policies into the practice had not yet been sufficiently embedded.
  • The provider organisation had systems to ensure compliance with the requirements of the duty of candour but this was not clearly understood by all staff at the practice.

Governance arrangements

The provider had endeavoured to implement at the practice governance arrangements which were consistent with the whole provider organisation.

  • Structures, processes and systems to support good governance and management were clearly set out by the provider organisation. However, they had not been consistently well embedded within the practice. Systems and processes that had been put in place to support the governance were not utilised by all staff to support good patient care.
  • Most staff were clear on their roles and accountabilities. However, this was not consistently the case including in respect of safeguarding and infection prevention.
  • The provider had established policies, procedures and activities to ensure safety, these were available on a shared drive most staff knew how to access them but not all.
  • The provider did not have effective systems in place to assure themselves that the systems they had put in place were operating as intended.

Managing risks, issues and performance

The provider had implemented systems for managing risks, issues and performance however, these failed to adequately monitor the quality of service provided by the practice.

  • Performance against the quality outcomes framework (QOF) was carried out by the central team and was used for the benchmarking of the individual practices. End of year performance showed the practice was achieving well against QOF at 98%. The provider had implemented additional nursing support to help achieve QOF targets.
  • There were systems to identify, monitor and address risks to patient safety. However, some of the arrangements were not always well implemented or followed up. During the inspection we identified risks in relation to minor surgery, patient care, emergency medicines, equipment and infection control. Patient searches had not captured all patients that required monitoring.
  • There was oversight at a provider level of national and local safety alerts, incidents, and complaints however systems were not always well embedded at practice level, who were responsible for acting on them.
  • Clinical audits seen demonstrated some improvement on the quality of care and outcomes for patients. However, our inspection identified further concerns in relation to the quality of care at the practice which had not been highlighted through audits.
  • The provider had trained staff for major incidents and provided support as needed.
  • There was a business continuity plan in place which covered all practices within the provider organisation. However, this needed updating to ensure details relating to this practice were fully reflected in it.

Appropriate and accurate information

The practice had put in place systems to support the quality of information collected however our review of records identified concerns with practice information.

  • The provider had put in place new clinical systems and support to the practice which enabled them to collect data and support patient care. Training in the systems and ongoing IT support was provided to practice staff. However, while training and support had been provided this had not led to the effective utilisation of those systems.
  • The provider organisation routinely collected information for monitoring purposes. However, our inspection identified concerns with the quality of some of the information reported on the clinical system
  • The provider had reviewed the views of patients and used this information to support service improvements which had been implemented to support the practice in the delivery of care and treatment.
  • The provider organisation was aware of systems for submitting data or notifications to external organisations as required.

Engagement with patients, the public, staff and external partners

The practice sought to involve patients, and external partners in the delivery of services.

  • The practice had a patient participation group which met quarterly although membership of the group was small. There were mixed feelings about the usefulness of the group from the members we spoke with.
  • The service worked with local stakeholders such as the CCG in response to local priorities. They also worked with third sector organisation to improve the range of services available to patients.

Continuous improvement and innovation

There was evidence of improvement in the practice infrastructure. The provider had taken on this practice and brought into it systems and processes to support improvement. However, these had not been taken forward by some staff within the practice.

  • The provider had introduced systems of continuous learning and improvement of staff, through protected learning events and staff meetings for all staff across the organisation. Practice staff were given training in the new systems introduced.
  • Changes to the clinical system, compatible across the organisation enabled staff at other sites to provide support remotely when needed. It also supported central monitoring of performance indicators.
  • The provider oversaw incidents and complaints and used these for sharing across the organisation as well as through local arrangements.

Please refer to the Evidence Tables for further information.

Checks on specific services

People with long term conditions

Inadequate

Families, children and young people

Inadequate

Older people

Inadequate

Working age people (including those recently retired and students)

Inadequate

People experiencing poor mental health (including people with dementia)

Inadequate

People whose circumstances may make them vulnerable

Inadequate