Aveley Medical Centre

This is the third inspection of Aveley Medical Centre. At the inspection on 12 December 2018 we rated the practice inadequate overall and issued an enforcement notice for a breach of regulation 17, good governance, we issued a warning notice and placed them into special measures.

We carried out an announced focused inspection on 24 April 2019 to review whether the provider had made improvements and was compliant with the warning notice served. The practice was not rated at this inspection.

We carried out a further comprehensive inspection of the practice on 31 July 2019 to follow up the breach of regulation and to re-rate the practice. The practice is now rated as requires improvement overall.

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
• information from the provider, patients, the public and other organisations.

We rated the practice as good for providing safe, effective and well-led services because:

• Staff were confident regarding the safeguarding system and procedures at the practice.
• Staff had received training for ‘Read coding’, an audit showed this was carried out accurately.
• Processes to monitor and action internal tasks was audited and showed work-flow was consistent, and there was no accumulation of documents or test results.
• Appropriate emergency medicines were held, stored securely and monitored to ensure they were safe for use.
• Training had been provided for non-clinical staff with regards to sepsis, and guidance was visible close to all computers screens.
• Dementia plans and patients care plans had been reviewed and updated recording frailty and vulnerability on their records to support staff members when dealing with these patients.
• The quality of referral letters, and document work flow through the practice, had been audited. This was now part of the on-going monitoring system to ensure an effective process was maintained.
• The cold chain procedure was documented and used effectively to ensure the safety of medicine.
• The practice held a comprehensive schedule of repeat audits to ensure patient outcomes were being monitored effectively and to drive improvement.
• The practice culture was seen to be open and honest between all staff members.
• The practice vision was signposted on an entire team photograph displayed prominently behind the reception desk at the practice.
• Processes for managing risk were well documented and available to all staff members. The monitoring of risks was undertaken regularly, recorded and actions acted on when needed.
• Audits had been carried out to ensure information used was accurate.
• Staff were provided protected time to carry out the roles of responsibility they had been given.
• All staff members were encouraged to be involved in the development of change and improvement at the practice.
• The practice had carried out its own internal survey of patients and staff members to gauge where improvement was needed.

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

Patient satisfaction data published in the national GP patient survey carried out January to March 2019 and published July 2019 was still low.

The number of carers identified was still low.

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

• Patient satisfaction data published in the national GP patient survey carried out January to March 2019 and published July 2019 was still low or very low.
• The number of patients attending for cancer screening was low.

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

The area where the provider must make improvements are:

• Improve patient satisfaction in particular; ease of getting through to the practice on the telephone, the overall experience of making an appointment, satisfaction of appointment times, and types of appointment.

The area where the provider should make improvements are:

• Continue to improve the system to identify patients who are carers.
• Improve the uptake and encourage patients to attend for cancer screening.
• Continue to improve patient satisfaction.

This service will remain in special measures. Services 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.

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

Aveley Medical Centre was previously inspected in December 2018 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, responsive and well-led services. We found the practice required improvement for providing caring services. As a result, we issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

We carried out an announced focused inspection at Aveley Medical Centre on 24 April 2019. The focused inspection was to review whether the provider had made improvements and was compliant with the warning notice. We also looked at the governance arrangements and the leadership of the practice. The practice was not rated at this inspection.

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.

This was an unrated focused inspection.

We previously found that:

• There were not clear responsibilities, roles and systems of accountability to support good governance and management.
• There was a system for receiving patient safety and medicine alerts, safety alerts were acknowledged but the practice failed to carry out searches to ensure patients were not at potential risk.
• There was no clinical oversight to monitor patients being prescribed high risk medicines, the practice had not identified all relevant high-risk medicines that required monitoring.
• Non-clinical staff had not received training to carry out tasks such as exception reporting and Read coding patients notes. As a result, we found exception reporting and Read coding to be unjustified and inaccurate which impacted on patient safety and care.
• We found there was an ineffective system to monitor incoming correspondence and completing system tasks to ensure timely review of patient care.
• The practice did not have all recommended emergency medicines available or a relevant risk assessment. The practice did not have a system for documenting checks on emergency medicines.
• We found that the practice did not have adequate systems and processes in place to ensure the safe management of medicines. For example, there was a system in place to ensure that medicines that required cold storage were stored safely, however this was not always effective.
• The system to ensure blank prescriptions and patient data were secure throughout the practice was not effective.
• There was an ineffective system to ensure lessons learnt from complaints and significant events resulted in improvements.
• The practices audits failed to implement changes and drive improvements.
• Non-clinical staff had not received sepsis training and were unaware of how to identify or deal with these patients.
• There was an ineffective system to monitor risks to patients who had not collected their prescriptions.
• The practice system to ensure safeguarding was managed effectively needed to be improved for example they did not hold accurate registers of patients where concerns had been raised or hold regular safeguarding meetings with external agencies to share concerns.
• The practice was unable to obtain details for dementia patients who had a document care plan on the system.
• We spoke with staff who felt that they did not have protected time to carry out additional responsibilities.
• The process to ensure locum staff had carried out training in accordance with regulations was ineffective.
• The practice failed to ensure staff had the appropriate authorisations in place to administer medicines (including Patient Group Directions or Patient Specific Directions). PGDs we review had not been authorised appropriately.
• The practice had not reviewed or monitored patient’s satisfaction data, published in July 2018.
• We found the quality of patient referral letters was varied and inconsistent.
• We found there was no evidence that an environmental health and safety risk assessment had been carried out.
• We found minimal evidence that ensured actions were initiated and carried out as a result of clinical and practice meetings.

At this inspection we found that:

• The leadership had changed since the previous inspection. The practice had established clearer responsibilities, roles and systems of accountability to support good governance and management however we found it required strengthening.
• The system to monitor and action safety alerts had been strengthened. The practice tracked, monitored and actioned some historical alerts however they had not implemented a system to ensure historical alerts were regularly reviewed.
• The practice had clear systems in place to monitor patients being prescribed high risk medicines which included clinical oversight.
• We reviewed unverified 2018/19 QOF exception reporting data and found that the practice had reduced their reporting, staff had received training however the newly implemented policy did not outline whether non-clinical staff continued to carry out exception tasks.
• Staff had received Read code training since the previous inspection, but the practice had not reviewed or audited their practice to ensure Read coding was carried out appropriately or accurately.
• There was an effective system to manage correspondence and pathology results.
• The system to monitor internal tasks was ineffective. We found there were 247 open tasks that had not been revisited.
• The practice had implemented a new system to ensure emergency medicine checks were documented however we found the practice did not have all recommended emergency medicines available or a relevant risk assessment. These were different from the previous inspection.
• The system in place to ensure that medicines that required cold storage were stored safely had been improved, the practice had developed a policy specific to their practice and implemented new log sheets. The practice policy clearly outlined staff responsible to monitor fridge temperatures however we found the recording of fridge temperatures was not always consistent.
• The system to ensure blank prescriptions had been strengthened and ensured prescriptions were secure throughout the practice.
• The process to ensure the security of patient data had improved.
• The practice had reviewed lessons learnt from complaints and significant events to ensure they drove improvements. The practice had one significant event since the previous inspection and had implemented changes to drive improvements.
• The practice had begun the data collection process for some clinical audits however they had not analysed or implemented changes to drive improvements.
• Non-clinical staff had received training and were aware of how to identify or deal with patients suspected of sepsis.
• The practice had implemented an effective system to monitor risks to patients who had not collected their prescriptions.
• We found the system to monitor safeguarding concerns was ineffective. The practice held inaccurate risk registers for children, they were unable to identify vulnerable adults as there was no risk register and missed appointments for vulnerable children and adults were not appropriately followed up.
• The practice had planned to carry out care plan reviews for patients with dementia however due to unforeseen staff absences this had been delayed. We found that the practice was able to access four out of 71 dementia care plans.
• Staff we spoke with during the inspection said they were not given protected time to carry out additional responsibilities however we found since the previous inspection the practice had allocated time in their daily calendar to allow staff to have protected time to carry out additional responsibilities.
• The practice had an effective system to ensure recruitment checks for locum staff were consistent and were able to monitor training requirements.
• The practice had improved the system to ensure staff had the appropriate authorisations in place to administer medicines (including Patient Group Directions or Patient Specific Directions).
• National GP patient survey data, published in July 2018, had been reviewed. The practice had carried out an internal survey and implemented an action plan as a result of their findings.
• The practice had implemented a template to ensure referrals were consistent. We found referrals were appropriate, followed up and of a good quality.
• There was an effective system to monitor health and safety risks to patients.
• Regular clinical and practice meetings had been implemented and actions were documented and reviewed.

In conclusion, although there had been some progress since the last inspection, there were a number of areas where the practice had not fully complied with the warning notice and further improvements were required. We will be monitoring this practice over time and will be carrying out a comprehensive inspection in the near future, to re-rate the practice and to ensure sufficient improvements have been made to keep patients safe.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

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 announced comprehensive inspection at Aveley Medical Centre on 12 December 2018 as part of our inspection programme. The practice was previously rated Good in May 2015.

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:

• The practice did not have clear systems and processes to keep patients safe.
• The practice system to ensure safeguarding was managed effectively needed to be improved for example they did not hold accurate registers of patients where concerns had been raised or hold regular safeguarding meetings with external agencies to share concerns.
• The process to ensure locum staff had carried out training in accordance with regulations was ineffective.
• The practice failed to act on all risks identified during environmental risk assessments.
• The system for monitoring health and safety risks to patients and staff was ineffective. We found there was no evidence that a health and safety risk assessment had been carried out.
• There was a system to monitor patients being prescribed high risk medicines however we found there was no clinical oversight to this task, the practice had not identified all relevant high-risk medicines that required monitoring.
• Non-clinical staff had not received training to carry out tasks such as exception reporting and Read coding patients notes. As a result we found exception reporting and Read coding to be unjustified and inaccurate which impacted on patient safety and care.
• We found that the practice did not have adequate systems and processes in place to ensure the safe management of medicines. For example, there was a system in place to ensure that medicines that required cold storage were stored safely, however this was not always effective.
• The practice did not have all recommended emergency medicines available or a relevant risk assessment. The practice did not have a system for documenting checks on emergency medicines.
• Clinicians knew how to identify and manage patients with severe infections such as sepsis. However, non-clinical staff had not received training and were unaware of how to identify or deal with patients suspected of sepsis.
• There was an ineffective system to follow up on urgent referrals to ensure patients had received appropriate timely assessment. We found the quality of patient referral letters was varied and was not consistent.
• The practice failed to ensure staff had the appropriate authorisations in place to administer medicines (including Patient Group Directions or Patient Specific Directions). PGDs we review had not been authorised appropriately.
• Learning and analysis of safety incidents did not consider all aspects of care, there was no systems in place to ensure changes had been implemented following a significant event to ensure similar scenarios did not reoccur.
• There was a system for receiving patient safety and medicine alerts however we found it to be ineffective for mitigating the risks to patients. Safety alerts were acknowledged but the practice failed to carry out searches to ensure patients were not at potential risk.
• There was an ineffective system to monitor risks to patients who had not collected their prescriptions.
• The system to ensure blank prescriptions were secure throughout the practice was not effective.
• The process to ensure the security of patient data was ineffective. We found staff did not ensure the protection of secure data.

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

• Although performance data was in line or above local and national averages, the practice had above national average rates of exception reporting. There was an inadequate system to ensure patients were being exception reported accurately. We found multiple examples of where exception reporting had been unjustified.
• The practice had an ineffective system to Read code patients notes. We found non- clinical staff carrying out this responsibility had not received appropriate training to ensure they understood the importance of accurately read coding patients notes.
• The practice had carried out clinical audits to review medicines. We found the audits failed to implement changes and drive improvements.
• The practice was unable to obtain details for dementia patients who had a document care plan on the system.

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

• National GP patient survey data, published in July 2018, showed below national and local averages for patient satisfaction regarding access to services. The practice had not reviewed the data or monitor patient’s satisfaction levels as a result.
• The practice reviewed complaints and highlighted lessons learnt however we found lessons learnt did not always encourage change or improvements to reduce the likelihood of similar complaints from reoccurring.
• The practice website did not encourage an open and accessible service. The website highlights patients are only allowed to discuss one concern during one consultation however the website does not state whether patients are able to book another appointment to discuss additional concerns.

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

• The overall governance arrangements were ineffective, as a result we identified concerns that put patients at potential risk.
• We found the practice culture did not effectively support high quality sustainable care. The tension between leaders did not encourance patient centred care.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• While the practice had a vision, that vision was not supported by a credible strategy.
• 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 spoke with staff who felt that they did not have protected time to carry out additional responsibilities.
• We found there was an ineffective system to monitor incoming correspondence and completing system tasks to ensure timely review of patient care.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

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

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The CQC comment cards the practice received were positive regarding the care and treatment patients had received however there were two mixed reviews regarding access to the service.
• There was an ineffective system to monitor patient’s satisfaction levels. The practice had not carried out a review of national GP patient survey data published in July 2018.
• There was an ineffective system to ensure lessons learnt from complaints resulted in improvements.
• The practice had identified a low number of patients who were carers.

The areas where the provider must make improvements are:

• 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:

• Develop systems and processes to identify carers to ensure they receive appropriate support.
• Consider training needs for non-clinical members with regards to sepsis.
• Strengthen processes to document dementia care plans.
• Improve quality and documentation of referral letters.

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.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice