Archived: Market Hill 8-8 Centre

Updated 18 February 2016

The practice shares occupancy of the Ironstone Centre in Scunthorpe with other practices and healthcare providers. A community car park with associated fees is located outside of the Centre. The practice has an Alternative Provider Medical Services (APMS) contract and has 5149 patients on the practice list. The majority of patients are of white British background. The largest proportion of patients are in the birth to four year age range and 24 to 40 year age range.

The practice scored two on the deprivation measurement scale, which is the second highest decile. The overall practice deprivation score is higher than the England average (the practice is 38.5 and the England average is 23.6). People living in more deprived areas tend to have greater need for health services.

The practice did not have any salaried GPs. They used locum GPs. There was one permanent practice nurse and health care assistant currently working at the practice. Other members of the nursing team were on sick leave. The practice had not had a permanent nurse at the practice since 23 December 2015. Locum nurses were used. There was an assistant practice manager who joined the practice in December 2015 and administrators, some of whom were on sick leave.

The practice is open between 8am and 8pm Monday to Saturday and 10am to 2pm on Sunday. Patients requiring a GP outside of normal working hours are advised to phone the local practice and their call is diverted to the local Out Of Hours Service or NHS 111.

Updated 18 February 2016

Letter from the Chief Inspector of General Practice

INADEQUATE

We carried out an unannounced comprehensive inspection at Market Hill 8-8 Centre on 6 January 2016. Overall the practice is rated as inadequate.

• We identified five breaches of the HSCA (RA) Regulations 2014; two of extreme seriousness and three of high seriousness. These related to safe care and treatment, safeguarding service users from abuse and improper treatment, receiving and acting on complaints, good governance and staffing.

Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because resources, systems and processes were not in place to keep them safe. For example, sufficient staffing for the smooth running of the service and to fully meet the needs of patients, the management of patients medicines, the call and recall of patients, the system for reviewing hospital discharge and clinic letters, supervision and support of staff and the management of safeguarding. We had serious concerns about the management of all the patients at this practice.
• Not all staff were clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, when there were unintended or unexpected safety incidents, reviews and investigations did not take place or were not thorough enough to support improvement. Action was not taken to mitigate future risk and so safety was not improved. There were no investigation records available and no records to show patients had received a written apology.
• Data, records and feedback from staff showed that care and treatment was not delivered in line with recognised professional standards and guidelines. For example the practice performed significantly below the national average in respect of patients with COPD, asthma, mental health and Osteoporosis.
• Reviews of patient records identified serious concerns with the way patients were managed.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• We observed members of staff were courteous when speaking with patients. This was aligned with the views of other patients. However, we also noted that patients were not always treated with compassion, dignity and respect by the nature of the complaints received and the very fact that patient’s basic needs were not always being met.
• Patients were unable to always access the care they needed. Services were not set up to support patients with complex needs or patients in vulnerable circumstances.
• Patients were frequently and consistently not able to access appointments and services in a timely way. This included access to emergency appointments. Patients experienced unacceptable waits for some appointments and services. Patients were at risk of harm and poor outcomes because they did not always receive the care they needed.
• The service had little or no clinical governance systems (clinical governance is a system through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish). There was evidence that known risks had not been acted on and despite the known risks, quality monitoring arrangements that had previously been in place had ceased to happen.
• The arrangements for governance and performance management did not operate effectively. The service did not carry out audits to ensure that clinicians working at the service were providing safe and effective care and were given the opportunity to identify opportunities to improve their practice and outcomes for patients. There was no system in place to monitor outcomes of intervention including holding clinicians to account for their clinical decisions. There was no system in place to support peer review and enable shared learning.
• The practice had a fractured staff group with high turnover of staff and had a high number of staff who were off sick. The practice did not have any permanent GPs and used all locum GPs. There was no clinical leadership at the practice and staff were not supervised or competency assessed. We witnessed an apparent high level of stress with at least two members of staff. Lack of support and communication from leaders was a common concern from staff. There was evidence of a defensive and blame culture.

In relation to all of the areas of concern identified, NHS commissioning organisations were informed to ensure any of the risks identified during our inspection were investigated.

Following our inspection, due to the serious concerns identified we urgently varied the conditions of provider’s registration with the Care Quality Commission (CQC) under section 31 of the Health and Social Care Act 2008 and stopped the provider Danum Medical Services Limited (DMSL) from providing GP services at Market Hill 8 - 8 Centre from 12 January 2016. The provider is allowed 28 days to make an appeal against this decision.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for people with long-term conditions.

• The safety of care for people with long-term conditions was not a priority and there were limited attempts at measuring safe practice.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital. We were told nursing shortages had meant patients in this group had not received the care they should. Performance for indicators related to COPD and diabetes was significantly lower than the national average.
• Performance data suggested the practice had a high rate of unscheduled admissions and A&E attendances with high rates of diabetes and COPD admissions.
• Home visits were not available when patients needed them.

• The care of patients with long-term conditions was not managed in a holistic and co-ordinated way.
• None of these patients had a named GP as the practice did not have any permanent GPs. Few of these patients had a personalised care plan.
• Structured annual reviews were not always undertaken to check that patients’ health and care needs were being met. For example, asthma reviews were carried out by telephone and the practice was unable to confirm how many of the 247 patients at the practice who were diagnosed as having asthma had received an annual review.

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for the care of families, children and young people.

• The safety of care for families, children and young people was not a priority and there were limited attempts at measuring safe practice. A large percentage of the practice list was children from birth to four years.
• There were no systems to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk.
• Childhood immunisation rates for the vaccinations given were all below the CCG average for under two year olds. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from 0.9% to 90.6% compared to the CCG average of 3.7% to 95.9% respectively. There was no comparable data against CCG averages in respect of five year olds. However, the data was low in some areas ranging from 77% to 90%.
• Children were not always offered emergency appointments when needed and were being referred to 111 or A&E unnecessarily.
• There were 68% of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding 5 years (01/04/2010 to 31/03/2015), which was lower than the national average figure for England (82%).

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for older people.

.There was little evidence to show the care of older people was managed in a holistic way.

• Little attempt had been made to respond to older people’s needs and access for those with poor mobility or who were housebound was limited. The practice could not provide any information in respect of home visits.

The leadership of the practice had little understanding of the needs of older people and were not attempting to improve the service for them. Services for older people were therefore reactive, and there was a limited attempt to engage this patient group to improve the service.

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for the care of working-age people (including those recently retired and students).

• The age profile of patients at the practice is mainly those of working age people in the second most deprived decile but the services available did not reflect the needs of this group.
• The practice offered extended opening hours. However, access to appointments during this time was not always meeting people’s needs.
• There was a low uptake for both health checks and health screening.

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

• Data showed outcomes for patients were comparable to the CCG and national average; some above and some below.
• We were told there is good access to mental health services including drug and alcohol services
• The practice did not have the resource in place that allowed clinicians to always follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.
• Staff had not received training on how to care for people with mental health needs.

Updated 18 February 2016

The provider is rated as inadequate for providing safe, effective, caring, responsive and well-led services. Concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is therefore rated as inadequate for the care of people whose circumstances may make them vulnerable.

· The safety of care for people whose circumstances may make them vulnerable was not a priority and there were limited attempts at measuring safe practice.

• The practice did not hold a register of patients living in vulnerable circumstances. It was unable to identify the percentage of patients who had received an annual health check. The practice did not routinely work with multi-disciplinary teams in the case management of vulnerable people.

· Of the patients on the practice register with a learning disability only two out of the 18 had been subject to an annual health review.

· Some staff knew how to recognise signs of abuse in vulnerable adults and children. However, there was insufficient attention to safeguarding adults and children. We were told that there were no risk register markers for children on their records to alert staff that patients were deemed at risk. There was no practice safeguarding lead. We saw two specific records which showed safeguarding issues had not been managed appropriately.

· It did not have the resource in place that allowed clinicians to always follow up patients who may be vulnerable and who had attended accident and emergency (A&E).