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Archived: Hillside Bridge Surgery Inadequate

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Inadequate

Updated 17 August 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? – Inadequate

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection of Hillside Bridge Surgery on 03 July 2018. The current provider, Dr Poonam Jha, registered the location with the CQC in October 2017 after taking over the management of the surgery on 01 June 2017. There was some continuity of staffing between the previous and current provider.

At this inspection we found:

  • The practice did not have appropriate systems in place to manage risk so that safety incidents were less likely to happen. When incidents did happen, we saw that significant events forms were incomplete and there was limited written evidence of dissemination to staff, learning from these incidents or changes in policies or procedures.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Feedback from six of the eight patients we spoke with on the day of inspection emphasised concerns regarding the practice and specifically the unhelpful and negative attitude of some staff members. A number of patient comment cards also reflected these concerns; as well as highlighting issues relating to accessing appointments and contacting the practice. One patient told us they were frightened to ring the practice.
  • The practice did not have reliable systems for the appropriate and safe handling of medicines.
  • The practice could not provide evidence of DBS checks for five staff who had worked for the previous provider; this included a GP and a nurse. (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.)
  • Not all staff at the practice had received up to date training. This included child and adult safeguarding training and infection prevention and control.

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

  • The provider must ensure that safe care and treatment is provided in a safe way to patients.
  • The provider must 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:

  • Continue to review and improve the identification of carers to enable this group of patients to access the care and support they may require.
  • Review and improve their approach to the management of infection prevention and control within the practice.
  • Continue to review and improve the uptake of cancer screening at the practice.
  • Improve the approach to auditing infection prevention and control in the practice to ensure that all areas of the practice are reviewed.

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 17 August 2018

We rated the practice as inadequate for providing safe services.

The practice was rated as inadequate for providing safe services because:

The provider did not appropriately assess the risks to the health and safety of patients who were receiving care and treatment. In particular:

  • The storage and handling of vaccines by the provider did not reflect best practice guidance.
  • The provider could not evidence Disclosure and Barring Service (DBS) checks for all members of the staff team. (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 practice did not have a system in place to monitor the appropriate use, distribution and storage of prescription pads in line with NHS protect guidance.
  • The system that was in place to manage the administration of Patient Group Directions (PGDs) was not effective and did not keep people safe. A PGD is a written instruction for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.
  • Medicines in the practice were not monitored or stored correctly and posed a potential risk to patients.
  • The process and management of significant events was incomplete and there was limited written evidence of dissemination to staff, learning taking place or changes in policies or procedures as a result of these.
  • The registered person had failed to review and maintain oversight of the immunisation status of the staff team, in line with the guidance ‘immunisation against infectious diseases (‘The Green Book’ updated 2014).

Safety systems and processes

The practice did not have clear systems to keep people safe and safeguarded from abuse.

  • The practice did not have appropriate systems to safeguard children and vulnerable adults from abuse. The provider was unable to assure us that all staff had received up-to-date safeguarding training including the practice manager. Not all staff were aware of who the nominated safeguarding lead was.
  • We saw that safeguarding meetings were held and that members of the multi-disciplinary team attended these.
  • The practice could not evidence DBS checks for five members of staff who had transferred to them from the previous provider. This included a GP and a nurse. We asked the practice to action this immediately. We received a written assurance the week after the inspection that this was being progressed.
  • Staff who acted as chaperones were trained for their role.
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • During our inspection we identified that there were gaps in the recruitment systems of the practice. In some cases, the practice were unable to provide evidence of proof of identity of the staff member, completed induction checklists, evidence of satisfactory conduct in previous employment or staff contracts.
  • Infection prevention and control (IPC) audits undertaken by staff at the practice only partially considered the practice environment. Areas which were not assessed included the patient and staff toilets, utility rooms and public areas.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • 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. We were told the lead GP could offer additional clinics if necessary.
  • The practice did not ensure that there was an effective induction system for all temporary or locum staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.
  • We were not assured that all window blinds at the practice conformed to the appropriate EU regulation (Directive 2001/95/EC). This presented a risk to the health and safety of staff and patients.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • The systems for managing and storing medicines, including vaccines, did not keep patients safe. We viewed records for the main refrigerator where vaccines were stored. These were not always completed and we saw a gap of 11 days in 2017 where refrigerator temperatures were not monitored. No action had been taken by the practice in relation to this, and the practice had not recorded this as a significant event.
  • A second vaccine refrigerator, which staff told us was used to store vaccines when they arrived at the practice and diagnostic kits which required refrigeration, was not monitored at all.
  • We observed an open storage container in a utility room which contained a large amount of medicines. The practice could not account for these medicines and there was a potential risk to patients as we observed that the door was unlocked on a number of occasions.
  • We were not assured that the system to manage PGDs kept people safe. Signatures on one PGD we viewed were not in chronological order and a further PGD we viewed which had been in use from 01/07/2017 had not been signed by the authorising manager as required. The same document was not signed by the nurse until 01/01/2018. We were told by the practice that 93 of the relevant vaccines had been administered to patients between 01/06/2017 and the time of our inspection.
  • The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice did not present an overall good track record on safety.

  • There were comprehensive risk assessments in relation to building and environmental safety issues.
  • However, COSHH risk assessments (Control of substances hazardous to health) for all cleaning chemicals stored in the practice, did not reflect the chemicals stored.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice did not sufficiently learn and make improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The practice did not have appropriate systems in place to manage risk so that safety incidents were less likely to happen. When incidents did happen, we saw that significant events forms were incomplete and there was limited written evidence of dissemination to the team, learning from these incidents or changes in policies or procedures.
  • We saw that there was a system in place to manage alerts but this was not effective. We saw that a file which contained copies of alerts and a spreadsheet to track progress, was last updated to on 03/05/2017 and that the documentation for managing the alert was incomplete. This pre-dated the current providers’ involvement with this service.

Please refer to the Evidence Tables for further information.

Effective

Inadequate

Updated 17 August 2018

We rated the practice as inadequate overall for providing effective care . The population groups Families, Children and Young people and Working Age people were also rated as inadequate for providing effective care. All other population groups are rated as requires improvement.

We rated the practice as inadequate for providing effective services because:

  • On the day of inspection, we found that patients were at risk of not receiving effective care or treatment.
  • Specific immunisation rates for children were below national averages. This was particularly concerning given a recent measles outbreak in the city.
  • Flu vaccine uptake rates for older adults was below national average.
  • Uptake rates for cancer screening was generally below CCG averages and significantly below national averages.
  • The provider could not evidence that end of life care was well managed in all cases.
  • The assessment of individuals with dementia was poor.
  • We did not see effective staff management or communication with the entire staff team.

Effective needs assessment, care and treatment

The practice had a system to keep clinicians up to date with current evidence-based practice. However, we did not see that guidelines and standards were discussed fully in meetings or shared with the staff team.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The practice used technology to improve care planning, treatment and to support patients’ independence.
  • The practice were able to refer patients to a social prescriber.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

This population group is rated as Requires improvement.

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication and were offered priority appointments.
  • Data forwarded to us by the clinical commissioning group (CCG) showed that the Flu vaccine uptake for adults aged over 65 years in 2017/2018 was 59%, the national target was 75%.
  • The practice maintained close links with the community matron to reduce admissions and inappropriate referrals.
  • Patients aged over 75 were offered an annual review. This included a review of their medicines which could be conducted by the pharmacist in their own home if necessary.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

This population group is rated as Requires improvement.

  • Patients with long-term conditions had one structured annual review to check their health needs were being met. The reviews considered the mental health and well-being of the person and their medicines needs. Care plans when provided, where appropriate.
  • Staff who were responsible for reviews of patients with long-term conditions had received specific training.
  • The practice participated in the CCG initiative Bradford Breathing Better, this included the provision of a proactive ‘rescue pack’ for the patient which included steroids and antibiotics in the winter for exacerbations of the condition.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).

Families, children and young people:

This population group is rated as Inadequate.

  • Under the previous provider, Childhood immunisation uptake rates for 2016/2017 were below the target percentage of 90% or above. On the day of inspection, the practice told us that their overall current uptake for immunisations was 77% for two year olds and 67% for five year olds. The practice offered opportunistic immunisation and contacted families to promote uptake. CCG data forwarded to the CQC showed that four out of six indicators for childhood immunisations were below target.
  • A maternity and healthy start event had been held at the practice.

  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • The practice held quarterly meetings with the health visiting team to discuss any safeguarding concerns or children with complex needs.
  • Ante-natal and post-natal care was provided by the midwifery service within the same building.

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

This population group is rated as Inadequate.

  • Under the previous provider, the practice’s uptake for cervical screening in 2016/2017 was 48%, which was significantly below the 80% coverage target for the national screening programme. Staff had been incentivised to encourage patients to attend for screening (see evidence table for additional data).
  • The practice’s uptake for breast cancer screening under the previous provider was below the national average. The practice’s uptake for bowel cancer screening under the previous provider was below the national average but comparable to the CCG average. The practice did not submit any data to CQC for 2017/2018.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.
  • The practice offered 24-hour blood pressure monitoring and electrocardiograms (ECG) which is a test which measures the electrical activity of your heart to show if it is working normally. This reduced the need to attend other secondary services.

People whose circumstances make them vulnerable:

This population group is rated as Requires improvement.

  • End of life care was reviewed at multi-disciplinary meetings and we were told these meetings considered the needs of those whose circumstances may make them vulnerable. However, patient notes reflected that not all patients who were coded as requiring end of life care were reviewed.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers, refugees and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.
  • The practice held a register of patients with a learning disability. Longer appointments were allocated to enable annual reviews to be completed. We saw that for 2017/2018 the practice had achieved the maximum QOF points available for this indicator.

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

This population group is rated as Requires improvement.

  • The practice were participating in a programme to offer annual physical health reviews to patients with serious mental illness and would refer patients when necessary to the local mental health team.
  • Patients were also referred for interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication or collect their prescriptions.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. Alerts were placed on the patient record to increase the screening of at risk patients. When dementia was suspected there was an appropriate referral for diagnosis. However unverified data for 2017/2018 showed that the practice had performed poorly in this area, scoring only 17.8 of the 50 points available.

Monitoring care and treatment

The practice had a programme of quality improvement activity and it had reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The practice were aware of areas where they needed to improve the uptake of health interventions. This included areas such as immunisations for children and adults.
  • The practice used information about care and treatment to make improvements and had undertaken clinical audits.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff did not always have the skills, knowledge and experience to carry out their roles.

  • Staff had some knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews. They attended meetings and events with peers.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Records of skills, qualifications and training were maintained but these were not up to date and we saw that a number of staff had not attended some training; for example, child and adult safeguarding training and infection prevention and control (IPC) training. Staff told us that were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. The practice told us that all staff had had an appraisal within the last year, however, one member of staff we spoke with said they had not had an appraisal.
  • The practice had not completed induction programmes and processes for all locum and permanent staff.
  • The practice management were aware of some issues with staff conduct, however, there was not a clear approach for supporting or managing this situation.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • We saw that clinical meetings had been regularly held since April 2018. However, we spoke with one GP who told us they did not attend meetings, had not received minutes and were not aware of any ongoing safeguarding issues.
  • The practice shared information, with liaised with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.

Helping patients to live healthier lives

Staff were not consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. A palliative care register was in place but not all patients who were coded as requiring end of life support were reviewed in the appropriate meeting.
  • The practice had identified a carers champion. Staff were allocated to lead roles and responsibilities to encourage patients to attend for screening.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health. Patients could be referred to a social prescribing scheme. But not all relevant staff were aware of the support available.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

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

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

Please refer to the evidence tables for further information.

Caring

Requires improvement

Updated 17 August 2018

We rated the practice as

requires improvement

for caring.

We rated the practice as requires improvement for providing caring services because:

  • There were times when patients did not feel well supported or cared for.
  • Feedback from patients was not always positive and we did not see evidence that the practice had responded appropriately to this.
  • The practice had identified less than 1% of the population as carers.

Kindness, respect and compassion

We saw evidence which indicated that not all staff treated patients with kindness, respect and compassion.

  • Feedback from patients was not consistently positive about the way staff treat people. Feedback from patients on the day of inspection was that some staff were rude and unhelpful. One patient told us they were frightened to contact the practice.
  • The majority of staff demonstrated that they understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • GP patient survey results related to the previous provider. However, there was some continuity of staffing between the current and previous provider including a GP and a nurse. The practice had undertaken a patient survey in May 2017 and 90% of patients said they were treated with care and concern.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They 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) and we saw posters displayed relating to this.

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available. Information leaflets, feedback forms and health promotion information was available in different languages. The practice had recruited staff who were reflective of the local population and able to speak at least 11 different languages, including those of several eastern European countries.
  • Staff told us they helped patients and their carers find further information and access community services and support. They helped them ask questions about their care and treatment.
  • The practice had identified less than 1% of the practice population as carers.

Privacy and dignity

Most of practice staff we observed respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered them a private room to discuss their needs.
  • Two patient comment cards stated the privacy and dignity of patients was not maintained.

Please refer to the evidence tables for further information.

Responsive

Inadequate

Updated 17 August 2018

We rated the practice, and all of the population groups, as Inadequate for providing responsive services. The issues that led to the rating of inadequate impacted on all of the population groups.

We rated the practice as inadequate for providing responsive services because:

  • Services did not always meet people’s needs.
  • The provider did not respond appropriately to complaints. The provider did not document verbal complaints and could not be assured that when these complaints were received they were managed appropriately, investigated and the necessary action taken to respond and learn from the complaint.
  • Patients and staff told us there were ongoing issues with the telephone system.

Responding to and meeting people’s needs

The practice had and continued to make some changes in response to patients’ feedback. As these changes were made the practice asked for patient feedback and liaised with the patient participation group (PPG).

  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours. The practice were involved in a local GP federation and were allocated 50 additional appointments per month for patients to be seen at allocated sites throughout the city, between 6.30pm and 9pm Monday to Friday.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services. Visits, medicines reviews and vaccinations could all be arranged at the patients’ own home if necessary.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.

Older people:

  • All patients over 75 had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP, healthcare assistant and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to poor mobility or illness.
  • The practice liaised with the pharmacist to arrange a medicines delivery service for housebound patients.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times would be adjusted to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this. The practice liaised with the health visitor regarding any concerns they had identified.
  • All parents or guardians calling with concerns about a child under the age of five were offered a same day, priority appointment when necessary.

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours.
  • Working patients could access a GP, nurse, physiotherapist and a health care assistant seven days per week, out of hours, as part of the work the practice were undertaking with a local GP federation.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice were aware of the needs of specific groups of their practice population, such as eastern European patients. They had recruited staff who were able to communicate in several different eastern European languages. Staff members would meet individually with patients to educate them about the NHS and the services that were available.

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

  • Staff interviewed had an understanding of how to support patients with mental health needs and those patients living with dementia.
  • Dementia reviews were undertaken using a recognised tool and patients would be referred to a memory clinic.

Timely access to care and treatment

Feedback was mixed regarding the ability of patients to access care and treatment from the practice within an acceptable 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. The practice had allocated one GP 15 minute appointments to reduce unexpected waits beyond scheduled appointment times and ensure that patient needs were met during consultations.
  • Patients with the most urgent needs had their care and treatment prioritised. Priority appointments were offered to children under five years old and older, more vulnerable adults.
  • Some patients reported that there were ongoing issues with appointment and telephone systems. The practice was aware of both these issues and additional appointments were being offered under the new provider. The practice manager also told us that discussions were underway to make significant changes to the telephone system which would allow more calls to be answered at one time and direct patients to the most suitable person.
  • GP patient survey results from July 2017 related to the previous provider. However, there was some continuity of staffing between the current and previous provider including clinical staff. We saw that patient responses to questions about timely access to services was below CCG and national averages. A survey undertaken by the practice in May 2018, noted that 84% of patients were happy with the opening hours of the practice.

Listening and learning from concerns and complaints

The practice told us that they took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • The practice manager told us that the majority of complaints were verbal and were managed on the day. The practice would respond to verbal complaints by speaking to or contacting the patient. However, these concerns were not documented or formally fed back to staff. We saw that for one written complaint regarding a prescription which had also been referred to NHS England, the practice had not documented this fact.
  • Information about how to make a complaint or raise concerns was available. Staff told us they treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice did not always have the opportunity to learn lessons from individual complaints and concerns or from an analysis of trends. Many of the complaints highlighted in the practice were verbal and not captured. We were told complaints would be informally discussed with the team but we were not assured that this happened for each occasion and that learning would take place.

Please refer to the evidence tables for further information

Well-led

Inadequate

Updated 17 August 2018

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

We rated the practice as inadequate for providing well-led services because:

  • The delivery of high quality care is not assured by the leadership, governance or culture of the practice.
  • There was little understanding or management of risks and issues.
  • An accurate training record was not maintained.
  • Not all staff at the practice had access to appropriate information.
  • There were gaps in the recruitment systems of the practice.
  • The process to manage alerts including those from the Medicines and Healthcare products Regulatory Agency (MHRA) did not keep people safe and was incomplete.
  • The provider had failed to ensure that all window blinds were compliant with EU regulation.
  • Meeting minutes did not evidence that issues, guidelines and standards were discussed fully in meetings or that outcomes and learning was shared with the staff team.
  • Responses to the GP patient survey 2017 and information we received from patients on the day of inspection was not always positive. The provider could not evidence they had acted on feedback from the relevant persons regarding the services provided.

Leadership capacity and capability

Leaders did not have the capacity and skills to deliver high-quality, sustainable care.

  • The clinical leader worked one session per week at the practice. On the day of inspection, we found that leaders and managers were not knowledgeable about the issues we highlighted in the practice.
  • Leaders at the practice understood a number of challenges relating to patients at the practice but had failed to identify challenges relating to their responsibility to keep people safe.
  • Leaders at all levels were not always visible or available to staff or patients.

Vision and strategy

The practice did not have a clear and implemented vision and credible strategy to deliver high quality, sustainable care.

  • A vision and a set of values had been developed, which stated that the practice team aimed to deliver high quality care to each patient group. However, we were told by staff and patients that some staff did not always adhere to these values.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population and participated in CCG initiatives.
  • The practice monitored progress against delivery of the strategy and provided feedback to stakeholders as necessary.

Culture

The practice did not have a culture of high-quality sustainable care.

  • Staff we spoke with stated they felt supported by managers at the practice. However, one staff member we spoke with told us that demand was increasing and there was a lack of capacity to meet that demand.
  • Leaders and managers at the practice did not act on behaviour inconsistent with the vision and values. A clinical member of staff we spoke with stated that there were issues with the communication skills of individuals within the reception team. When asked about this issue, the management said they had spoken to one member of staff but following our feedback they might consider further training.
  • We were told that the practice was taking steps to ensure that openness, honesty and transparency were demonstrated when responding to incidents and complaints. However, as the majority of complaints were verbalised to the practice and not documented, we were not assured this was always possible.
  • The provider was aware of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and that managers were supportive.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. Most of the staff team had received an annual appraisal in the last year. One member of staff told us they had not had an appraisal; this was difficult to assess as not all the necessary documentation was available.
  • Staff were supported to meet the requirements of professional revalidation where necessary.
  • The training records maintained by the provider showed that not all staff had received equality and diversity training.
  • There were positive relationships between staff and other visiting team members.

Governance arrangements

There were not clear responsibilities, roles and systems of accountability to support good governance and management.

  • The structures, processes and systems to support good governance and management were not fully understood or effective.
  • We saw that there were gaps in staff training, including child and adult safeguarding and infection prevention and control (IPC) training. We could not be assured that staff were clear about their roles and accountabilities including in respect of safeguarding and IPC.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. However, we saw that some of the terminology used in the IPC policy was outdated and required review.

Managing risks, issues and performance

There was no clarity around processes for managing risks, issues and performance.

  • We saw that there were ineffective processes in place which did not allow the practice to identify, understand, monitor and address current and future risks including risks to patient safety. This included areas such as recruitment and DBS checks. We saw that the provider had not fully responded to a previous alert in relation to window blinds in at least two clinical areas. The blinds did not comply with the appropriate EU regulation (Directive 2001/95/EC) and therefore posed a choking hazard to children or those that were vulnerable.
  • Practice leaders had oversight of safety alerts, incidents, and complaints. We saw that the processes to manage these did not support discussions with the entire staff team, support them to be managed fully or enable team members to learn from these events.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.

Appropriate and accurate information

Not all staff at the practice had access to or were aware of the appropriate, necessary and accurate information.

  • Quality and operational information was used to review and take steps to improve performance.
  • Quality and sustainability were discussed in relevant meetings; not all staff had sufficient access to information.
  • The practice 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 some areas of weakness that had been identified by the provider.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required; for example, to the CCG.
  • 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 practice was taking steps to involve patients, staff and external partners to support high-quality sustainable services.

  • There was a box in the reception area to capture patient comments. We were not told of any actions that were taken to improve services as a result of these comments. Friends and family test outcomes were fed back to the CCG.
  • There was an active patient participation group who reported that changes had been made as a result of feedback from them, for example, more appointments had been introduced.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • We saw that meeting minutes did not reflect in any detail the issues discussed. A programme of clinical meetings was only evident from April 2018 onwards. One GP told us they did not attend meetings and did not receive any notes from the meetings, which meant they were unaware of the issues discussed for example significant events.

Continuous improvement and innovation

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

  • The practice discussed and were aware of internal and external reviews of incidents and complaints. However, we were told that the information was not disseminated to all members of the team and therefore the practice could not be assured that this information was used to make the necessary improvements.

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