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Archived: Merseybank Surgery Inadequate

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Reports


Inspection carried out on 31 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We initially carried out an announced comprehensive inspection at Dr Iain Hotchkies Merseybank Surgery on the 14 July 2015 when the practice was rated inadequate and was placed into special measures. Services placed in special measures are re-inspected again within six months.

On 4 April 2016 we carried out an announced re-inspection of Merseybank Surgery when the practice had made improvements but remained inadequate for safety and continued in special measures for a further six months. Although improvements had been made, further improvement was still necessary and overall the practice was rated as requires improvement.

This most recent inspection was an announced comprehensive re-inspection undertaken on 31 January 2017 following the continued period of special measures. Overall the practice had received a period of eighteen months to improve since its initial rating of Inadequate. At this inspection we found that the practice had made only minor improvements in some areas, but had not progressed at all regarding other improvements required. Overall the provider has been given significant time to make improvements but the findings of this inspection indicate that they are not able to maintain the improvements required. As the provider has not been able to make more substantial improvements over a prolonged period of time, the practice is rated as inadequate.

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

  • Although some minor improvements were evident they did not fully reflect all the areas identified for improvement in the previous inspection reports. Significant shortfalls remained regarding the quality of the service.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons and actions were highlighted but were still not carried out. There was no understanding of the requirement to review incidents to ensure that learning had been achieved and this had been highlighted at the previous inspection.
  • When risks to patients were identified they were not always well managed and appropriate action was not always taken.
  • The practice had a number of policies and procedures to govern activity, but they were not all followed in accordance with what they contained.
  • Health checks, childhood immunisations and cervical screening rates remained lower than average compared with the local CCG and national averages.
  • A patient participation group had been implemented but the practice did not find it useful and there was limited benefit to the practice or its patients.
  • Improvements had been made to patient outcomes and data showed that the majority of patient outcomes were comparable to the CCG and national average.
  • Effectiveness at the practice had progressed and there was evidence that clinical audit was being used to improve patient outcomes.
  • All the patients we spoke to or provided written feedback said they were treated with compassion, dignity and respect.
  • The practice offered open surgeries each morning and fixed appointments each afternoon except Wednesdays when the practice was closed.
  • Patients had been informed that a merger of the practice was imminent but no formal arrangements had yet been agreed.

The areas where the provider must make improvements are:

  • Have systems and processes that are established and operated effectively to ensure that good governance is maintained.
  • Do all that is reasonably practicable to assess, monitor, manage and mitigate risks to the health and safety of patients.
  • Monitor and review that staff have the required training and understanding to enable them to carry out their roles effectively.
  • Have a system to obtain patient feedback and monitor verbal comments and complaints
  • Ensure care and treatment is provided in a safe way.
  • Take appropriate action whenever risks and issues are identified.
  • Ensure that care plans are in place for all patients that need them.
  • Have a system to ensure competency and understanding of training such as chaperoning and Data Barring and Service (DBS) checks.
  • Be able to demonstrate sufficient understanding of the requirements of the Health and Social Care Act 2014 and how to implement and maintain the necessary changes
  • Demonstrate that they have the necessary qualifications, competence, skills and experience required to undertake their role, such as mental capacity, Deprivation of Liberty Safeguards (DoLS) and leadership skills.

The areas where the Provider should make improvements are as follows :

  • Have a system to identify and support those patients that are carers.
  • Consider a continual review of procedures and guidance to ensure they are being followed.
  • Consider the needs of the practice population and make changes where appropriate such as increasing the number of staff or maximising the skills of existing staff to meet these needs.

This service was originally placed in special measures in July 2015. The service was kept under review for six months and a re-inspection was conducted in April 2016. The practice was advised that if there was not enough improvement further action could be taken in line with our enforcement procedures.

The practice was re-inspected for a third time in January 2017. Insufficient improvements have been made such that the rating remains as inadequate overall. We are therefore taking action in line with our enforcement procedures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 21 November 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

On 4 April 2016 we undertook a full comprehensive re-inspection of Merseybank Surgery. At that inspection we found that systems and processes were not embedded sufficiently to ensure patient safety. As a result of our findings the practice remained in special measures for a further six months and a warning notice was issued.

The Warning Notice issued on 9 June 2016 alerted the practice to areas where Regulation 17 had not been met. The parts of the regulation that the practice were failing to meet specifically impacted on the safe and well led domains. In particular there were no effective systems to:

  • Assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services)

  • Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity

  • Maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided

On 21 November 2016 we carried out a focused inspection of Merseybank Surgery. We went to check if the practice had achieved compliance with the Warning Notice issued on 9 June 2016.

At this inspection we found that some improvement had been made and some systems had been introduced but further improvements were still required to ensure that safety was maintained. In particular we found that :

  • Some systems had been implemented and there was evidence that these would be effective if they continued. They related to fridge control and cold chain process, legionella testing, audit, and call and recall of patients.

  • A number of protocols introduced to manage the practice were not yet embedded well enough and were not consistently followed. They did not reduce the risks that had been previously identified. These included building management and taking appropriate action when things went wrong, significant event recording, documentation of meetings to evidence discussion and protocols for two week waits.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 4th April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We initially carried out an announced comprehensive inspection at Dr Iain Hotchkies, Merseybank Surgery on the 14 July 2015 when the practice was rated inadequate and was placed into special measures. Services placed in special measures are reinspected again within six months.

We therefore carried out an announced re-inspection at Dr Iain Hotchkies Merseybank Surgery on 4 April 2016. The practice has made considerable improvement since our last inspection but were still inadequate for safety and will remain in special measures. We found that other improvements were still required and overall the practice is now rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Reviews and investigations were carried out, discussed and recorded. The process was not always completed to ensure that appropriate actions were taken in a timely manner.
  • Improvements had been made with regard to risks to patients and staff and some systems to assess and manage these had been implemented. Further improvements were necessary to ensure that processes remained effective and actions were taken when required. For example, there had been no gas, electrical and legionella checks by appropriate bodies.
  • Data showed that some patient outcomes had improved since our last visit. The practice were still outliers for some of the QOF (or other national) clinical targets. For example there were large variations in areas such as cervical screening, coronary heart disease and the prescribing of hypnotic and antibiotic medicines.
  • Some patient outcomes had improved substantially from the previous year such as those relating to blood pressure checks and foot examinations for patients with diabetes.
  • The practice had implemented a system of audit and monitoring and had carried out some checks on patients to ensure they were receiving the most appropriate treatment. Two cycle clinical audits were not yet completed.
  • All patients said they were treated with compassion, dignity and respect and felt cared for and involved in their treatment. Information about services was available and transferrable into different languages if and when required.
  • The practice had implemented a patient participation group and met with the group monthly.
  • The practice had a number of policies and procedures to govern activity. These now needed to be embedded into every day practice to ensure that they were effective. For example, to ensure that appropriate action is taken when things go wrong.

The areas where the provider must make improvements are:

  • Ensure that appropriate actions are taken when reviews and investigations are carried out.
  • Ensure that policies and procedures are embedded and appropriate actions are taken when things go wrong such as maintenance of the fridge to ensure that appropriate cold storage requirements are maintained.
  • Obtain the necessary checks and documents to evidence that gas, electrical and legionella checks have been carried out.
  • Ensure fire safety within the environment by carrying out regular checks of fire/smoke alarms, evacuations and introducing persons responsible for ensuring the safety of all staff and patients in the event of a fire.
  • Carry out clinical audits and re-audits to improve patient outcomes.
  • Ensure there are always adequately trained staff available to chaperone if required.

In addition the provider should:

  • Review the needs of the practice population and make changes where appropriate.
  • Continue to review, update and embed procedures and guidance into day-to-day practice.
  • Complete all infection control action

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on Monday 26th October 2015

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

On 14th July 2015 we carried out a full comprehensive inspection of Merseybank Surgery which resulted in a Warning Notice against the provider. The Notice advised the provider that the practice were failing to meet the required standards relating to Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe care and Treatment.

The part of the regulation that the practice were failing to meet specifically related to the management of medicines. At the time of the comprehensive inspection we found that the provider did not have an effective system, to ensure that medicines were managed in a safe and proper way. A number of medicines and equipment kept on the premises were found to be out of date.

On 26th October 2015 we undertook a focused inspection to check that the practice had achieved compliance with the Warning Notice which we issued on 10th August 2015. At this inspection we found that the practice had satisfied the requirements of the Notice.

Specifically we found that :

  • Risks had been assessed and steps had been taken to mitigate those risks
  • The practice had introduced systems to audit, assess and maintain the proper and safe management of medicines and equipment.
  • The practice provided assurances that those systems would be followed and would remain in place.

The rating awarded to the practice following our full comprehensive inspection on 15th July 2015 remains unchanged. The practice will be re-inspected in relation to their rating in the future.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General PracticeLet

Inspection carried out on 14th July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a new comprehensive inspection of Merseybank surgery on 14th July 2015. We have rated the overall practice as inadequate.

Specifically, we found the practice inadequate for providing safe, responsive and well led services. It was also inadequate for providing services for all the six population groups. Improvements were required to caring and effective services.

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

  • There was insufficient reporting, recording and reviewing of significant events and staff were not encouraged to follow formal processes and promote a learning culture.
  • Patients were at risk of harm because systems and processes were not in place to keep them safe. We found concerns in safeguarding, infection control, training, medicine management, access and quality and monitoring systems.
  • We found the practice had not taken all measures to identify, assess and manage risk. For example, the practice did not have robust systems for checking and recording medicines held at the premises or managing health and safety.
  • Prescriptions were not kept securely in line with national guidelines.
  • The practice did not have systems in place to monitor the quality of the service or determine whether the patients received the best treatments available to them.
  • All the patients we spoke with were very satisfied with access to appointments and told us that they were very happy with the service, the GP and the staff. CQC comments cards provided positive feedback; however the GP patient survey results, reviews left on public websites and the friends and family test were not always positive.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
  • There was no clear vision and strategy and no plans for the next twelve months or next five years other than to carry on as they were currently.
  • There was no patient participation group and no regular monitoring that patients were receiving a service they were happy with. Although there was a formal complaints procedure, complaints were mostly dealt with informally.

There were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve:

  • Implement a process to review significant events annually and disseminate learning to practice staff
  • Ensure medicine management systems are reviewed and reflect national guidelines.
  • Ensure appropriate infection control systems are in place, in line with national guidelines.
  • Provide safeguarding training to all staff at the required level for their role.
  • Ensure there are systems in place to regularly assess and monitor the quality of the services making sure policies and procedures are regularly reviewed as to their effectiveness and ensuring there is a clinical audit process in place with evidence of actions taken in improving patient care.
  • Ensure there are processes in place to identify, assess and manage risks relating to health, welfare and safety of patients.
  • Ensure staff receive regular appropriate training, specific to their role.
  • Undertake and record risk assessments, including those relating to health and safety and risks to patient safety.
  • Review responses from patients regarding the accessing appointments in order to make improvements to the service provided.
  • Regularly obtain patients’ views and act on the feedback received to improve the services provided for example with the development of a patient participation group.

Action the provider should take to improve:

  • Review staffing levels to ensure that there are enough staff to carry out the duties required to run the practice effectively.
  • Provide information to patients, in the form of easily accessible literature, posters and leaflets, about the practice, the services offered and signpost patients to other services in the area.
  • Hold regular meetings with staff, which are minuted, to discuss all aspects of the practice which relate to patient care and safety.
  • Risk assess and evidence which staff should have Disclosure and Barring Service (DBS) checks.
  • Provide chaperone training to staff who are required to undertake chaperone duties.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 24 April 2014

During an inspection to make sure that the improvements required had been made

During this inspection we reviewed the areas where we had found non-compliance at our inspection on 29 August 2013. We established improvements had been made and the issues highlighted in the last report had, on the whole, been addressed.

We met and spoke with the practice manager and Dr Iain Hotchkies, the GP.

We found there had been one new staff member recruited into the practice since our last inspection. We established that the provider had put their revised recruitment procedures into practice.

As a practice the GP and practice manager had judged that the reception staff did not require Disclosure and Barring Service (DBS) checks. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults, to help employers make safer recruiting decisions and also to prevent unsuitable people from working with children and vulnerable adults.

Inspection carried out on 29 August 2013

During a routine inspection

We spoke to five patients who had attended Merseybank Surgery on the day of our visit. They were mainly happy with the service provided by Dr Hotchkies, although there were also some negative comments.

One person said: "He has been excellent for me and my family. He is always pleasant and helpful. He has helped my son, my partner and me." One said: "He's good. He gives me enough time. He's a good listener." One or two patients stated they found he could be impersonal or brusque at times. One said: "He gets annoyed if you come often with the same thing."

We found that the open surgery system in the mornings was working well and mostly liked by patients. This system meant there were no appointments, and if people arrived by 11.30am they were guaranteed to see the doctor.

We found that staff were aware of the need to protect children and vulnerable adults from abuse, and that the training in this area was mostly up to date. We found that the building was suitable and well maintained, and there was enough space for patients and staff.

We found that Dr Hotchkies' practice could not demonstrate that it carried out effective recruitment processes.

We found that there were adequate systems for monitoring the quality of the service, but that further action could be taken to encourage patient feedback and patient participation.