Archived: Dr Jones SR Practice / Rigg Milner Medical Centre

We carried out an announced comprehensive inspection at Dr Jones Sr Practice / Rigg Milner Medical Centre on 30 October 2018, following which the practice was served a warning notice, as we found that the service was not carrying out safe, effective or well-led care. The practice was rated as inadequate overall and placed in special measures.

Following this, an unannounced focused inspection at Dr Jones SR Practice / Rigg Milner Medical Practice took place on 19 March 2019. At this inspection, we followed up on whether the provider had complied with our warning notice served following the last inspection. The provider had complied, but new breaches were identified, and requirement notices were served. A further comprehensive inspection took place on 4 June 2019, to review whether the provider could be taken out of special measures and to rerate them. At this inspection we found a number of breaches of the regulations and again rated the practice as inadequate overall.

The practice remained in special measures for a further six months and was issued with a new warning notice on 28 June 2019, as we found that the service had failed to establish sustainable and effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We then carried out an unannounced focused inspection at Dr Jones SR Practice / Rigg Milner Medical Centre on 20 August 2019. This inspection was completed to check whether the provider had complied with the requirements of the warning notice served on 28 June 2019.

During our focused inspection on 20 August 2019, we found that improvements had been made and that the provider had met the requirements of the warning notice served on 28 June 2019.

Whilst we found no breaches of regulations, the provider should:

• Continue to review and improve the system for handling complaints and the system for sharing learning from the complaints.
• Continue to monitor and improve the performance of cancer indicators.
• Continue to review and improve the outcomes from the national GP patient survey.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Dr Jones SR Practice / Rigg Milner Medical Practice on 4 June 2019 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at previous inspections on 30 October 2018 and 19 March 2019.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall.

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

• Although some improvements had been made the practice still did not have clear systems and processes to keep patients safe.
• Systems related to recruitment although improved still did not provide assurance that fit and proper staff were employed.
• Systems related to Legionella monitoring were ineffective.
• There were still a number of documents relating to care and management of patients that were not filed in a timely manner to the patient’s electronic record.
• Checks relating to emergency equipment were again not evidenced and the defibrillator would not be usable in an emergency.
• Although arrangements relating to fire safety had improved since our October 2018 inspection, there were no fire drills taking place.
• There was a lack of evidence that the practice learnt and made improvements when things went wrong.

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

• The practice was unable to show that all staff had received core training such as safeguarding and infection control.
• The practice had not assured themselves that advanced nurse practitioners had appropriate indemnity insurance in place.
• There was a lack of documentation in place relating to advanced nurse practitioners individual competences. There was a lack of assurance that advanced nurse practitioners were acting within their competency level and had access to appropriate individual clinical support.

These areas affected all population groups, so we rated all population groups as inadequate. In addition, the data for cancer screening was lower than the local and national average in several areas in the population group ‘working age people’.

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

• Feedback relating to patient experience was mixed.

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

• There was no online access to appointments.
• Although changes had been made to appointments, there were delays to patients in seeing clinicians past their appointment time.
• Patient feedback was mixed regarding access to appointments.
• The clinical staff structure and the impact of advanced nurse practitioners being unable to see patients under the age of two, had the potential to affect capacity for this group.
• Systems for managing complaints continued to be ineffective.

These areas affected all population groups, so we rated all population groups as inadequate.

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

• While the practice had made some improvements since our inspections on 30 October 2018 and 19 March 2019, it had not adequately addressed the Requirement Notices in relation to: the processes for scanning documents and recording them on the patient record; receiving and acting on complaints; governance systems and structures; the process around recruitment of staff. At this inspection we also identified additional concerns that put patients at risk.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• We could not be assured that the practice culture would effectively support high quality sustainable care.
• Some of the governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We saw limited evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation. In addition, ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Formalise the processes for identifying carers.
• Review all medicines authorisations to ensure that they contain the correct authorisation.
• Implement a system to monitor the consent process.
• Continue to review access to services.

This practice will remain 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.

The service will be kept under review and if needed could be escalated to urgent enforcement action.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an unannounced focused inspection at Dr Jones SR Practice / Rigg Milner Medical Centre on 19 March 2019. At this inspection, we followed up on whether the provider had complied with our warning notice, served following an announced comprehensive inspection at Dr Jones SR Practice / Rigg Milner Medical Practice on 30 October 2018. We were also responding to concerns that had been raised about the service.

During our inspection on 30 October 2018, we found that the service was not carrying out safe, effective or well-led care. Breaches of regulation were identified. We served a warning notice in respect of safety at the practice. This was because: staff files did not evidence whether appropriate recruitment checks had been completed; recommendations from a risk assessment hadn’t been completed and other risk assessments either weren’t completed or weren’t completed correctly, monitoring checks and tests for, fire alarm, defibrillator, calibration and portable appliances were not being completed; the vaccine refrigerator was overfull.

During our focused inspection on 19 March 2019, we found that improvements had been made and the provider had met most of the requirements of the warning notice. However, there were still breaches of regulation and further breaches were identified.

At this inspection we found:

• While the practice had made some improvements since our inspection on 30 October 2018, it had not completely addressed the Warning Notice in relation to the recruitment processes and Legionella monitoring.
• There were appropriate monitoring checks on emergency equipment.
• An external company had been booked to provide infection control training and to complete an infection control audit.
• There was a fire procedure that included up to date details of fire marshals. There were weekly fire alarm checks.
• Portable appliance testing and calibration of medical equipment had been completed.
• A premises risk assessment had been completed.
• Reception staff were routinely directing patients to the local walk in centre or A&E as they did not have clinical capacity to treat those patients.
• A monitoring system for prescription stationery had been set up. Prescription security still required further strengthening.
• Although documents containing information about the care and treatment required for patients had been scanned to the electronic system, they had not been matched to the patient record, putting some patients at risk.
• Leaders did not have the capacity to effectively manage the governance of the practice. Patients were put at risk due to this.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Implement a coherent system to evidence staff vaccination checks.
• Continue to strengthen processes relating to blank prescription security.
• Review clinical staffing to ensure that there is sufficient capacity to meet patient demand.
• Review governance structure to support effective systems and processes.

Although some further improvements were required, we were satisfied that the practice had made sufficient progress in relation to the Warning Notice. The practice will receive a further comprehensive inspection in the next few months where we will be checking progress against the outstanding matters and re-rating the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care