Naseby Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 5 out of the 6 quality statements in this key question. We did not look at consent to care and treatment during this assessment and the score for this quality statement remains unchanged from the previous inspection. At our last assessment, we rated this key question as inadequate. At this assessment, the rating has changed to requires improvement.

The provider did not have adequate systems to ensure that care and treatment were effective or delivered in line with current evidence‑based guidance. Despite changes to processes, we were not assured that clinical reviews would be completed thoroughly or within nationally recommended time frames. Although the provider had introduced measures aimed at improving the quality of medical records, they did not provide sufficient assurance that these would be implemented effectively or sustained.

The caretaker provider had undertaken comprehensive work to review patients’ treatment and improve outcomes. However, the provider did not demonstrate a full understanding of how this had been achieved or how they would maintain safe, effective, evidence‑based care moving forward. Engagement with the caretaker provider had been limited, and the provider did not have full oversight of the improvements required to ensure safe and effective clinical governance.

This represented ongoing breaches of in relation to safe care and treatment and good governance.
 

This service scored 42 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our previous inspection we found that the practice did not always make sure people’s care and treatment was effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Reviews of patients with long term conditions were not always done in a timely manner and as clinical staff did not always use templates when conducting care reviews, they often did not contain detailed information about the patient’s needs. Our review of clinical records found multiple records with inaccurate or incomplete information which could not be explained by the practice.

At this inspection, the provider showed us new policies which described how patients would be called for long-term condition reviews and how those reviews would be completed. However, it was unclear which staff member would be responsible for each step in the process, how they would ensure that each patient received the correct tests and how the process would accommodate the needs of patients with multiple long-term conditions. When we asked for clarification, the provider was unable to explain how this would work in practice.

Following this inspection the provider updated and expanded on this information however, we were not assured by this as it was not clear whether staff had been trained in how to use the new processes.

During this inspection we asked the provider how they would improve, monitor and maintain the quality of medical record keeping. They advised that newly recruited pharmacists would be responsible for undertaking record keeping audits for all staff, including those of the GP partners. We questioned if pharmacists would have the knowledge and skills required to be able to audit the medical records of a GP effectively and the potential conflict with providing constructive feedback to a doctor who may be their employer or supervisor.

Following this inspection the provider submitted an agreement from an external, independent GP to undertake a monthly medical records audit of records completed by the GP partners. However, it remained unclear if the plan was for pharmacists to audit all other records in the practice.

The concerns highlighted during our previous inspection related to the record keeping of the GP partners. The provider shared a plan for the external auditor to escalate any high-risk findings from the medical records audit to one of the partners. However, there was no contingency for external arbitration if it was records made by the partners that were in question and therefore, we were not assured that the proposed audit would be impartial or effective in improving the quality of record keeping.
 

At our previous inspection, we found the care and treatment of some patients did not comply with national guidelines, for example annual medication reviews had not been completed and abnormal test results had not been followed up for some patients with poorly controlled diabetes. We had serious concerns about the accuracy of some records including those relating to diabetic foot checks and therefore the competence of the staff completing them.

During this inspection we asked the provider to explain how they planned to address these issues. The GP partners had undertaken training in the management of some long-term conditions including diabetes and diabetic foot checks. The provider had indicated that excessive GP workloads had contributed to the fact that annual reviews had not been completed, patient assessments had been rushed and incomplete and follow ups had not been timely. They proposed plans to increase staffing levels using locum GPs and pharmacists as well as dedicated GP-led diabetes and asthma clinics and shared new processes to ensure that patients were called for annual reviews in a systematic way.

When we looked at the proposed plans further we saw a roster of clinics which included 2 full day long-term condition clinics. However, the provider had not used current data to establish the what the demand for long-term condition reviews would be to help inform decisions about how many extra staff were required. No evidence was provided to show that the extra staffing would provide the required number of appointments and the proposal to implement specific full day clinics would significantly impact the number of routine face-to-face appointments available on those days. We saw a standard operating procedure which described how a risk level will be assigned to patients but this was not linked to the planned dedicated long-term condition weekly clinics. It was unclear which patients would be offered appointments in these clinics. The provider’s action plan described training, upskilling, or recruiting allied health professionals to support dedicated asthma and diabetes clinics. However, neither the proposed locum nurse nor the pharmacists had specialist diabetes training and it was unclear whether existing staff would be upskilled and how long this would take. No evidence was provided to explain how the gap between starting a dedicated GP asthma and diabetes clinics and having additional staff trained and ready to support them would be safely managed. This risked there being insufficient resource for the proposed clinics leading to backlogs and delays for patients.

Following this inspection, the provider worked with an external consultancy to interrogate the current level of demand and align it to proposed staffing levels. However, we would need to see this developed further to provide assurance.

The planned system for long-term condition reviews required reception and administrative staff to contact patients and arrange review appointments. Receptionists at the practice had dual receptionist and administrator roles. When we asked the provider how receptionists would be freed from providing reception duties to complete administrative tasks, they were unable to explain how this would be achieved with the current staffing level.

Following this inspection the provider increased their reception / administrative resources from 2.5 whole time equivalents (WTE) to 2.75 WTE. In the NHS, a WTE staff member works 37.5 hours per week. Using WTEs allows the hours worked by part-time staff members to be aggregated into the equivalent of a whole-time staff member. It remained unclear whether this increase in staff resource was sufficient to ensure that patients would be managed in a safe and timely manner.

The provider planned to use a suitably trained healthcare assistant (HCA) to provide support with long-term condition reviews. This consisted of taking standard measurements such as height and weight, taking blood samples for testing and completing condition-specific tests such as foot checks. The new policy stated that these appointments slots would last 20 or 30 minutes. The provider did not provide evidence to show that they had calculated that the hours worked by the HCA would provide sufficient appointments to ensure patients were reviewed in line with national guidance, whilst leaving sufficient routine HCA appointments available. When asked, the provider could not clearly describe how the correct blood tests would be requested prior to the initial HCA appointment or what the clinical supervision arrangements would be for the HCA.

Following this inspection, the provider sent us a more detailed breakdown of the demand for long-term condition reviews, an updated policy which showed the HCA would use existing clinical templates to identify and request the correct blood tests for each patient and who would provide clinical supervision.

The evidence presented did not assure us that the proposed systems and staffing resources would be sufficient to ensure that all patients would receive the required care and treatment in line with national guidance or that capacity was maintained to allow comprehensive assessments and follow up of test results.
 

During the suspension period some staff had their employment transferred to the caretaker provider and were provided with training and development. Despite being encouraged to do so, the GP partners had limited contact with either their existing staff or the caretaker provider. When we asked the provider how they had involved existing staff in the process of planning for the lifting of the CQC suspension they told us that they had held one staff meeting lasting 10 minutes. No evidence was provided to show that the provider had taken steps to understand what training staff had undergone or the systems and processes staff were now working with. For example, the caretaker had changed the appointments system and trained all the reception staff in care navigation. This equips reception staff to be able to make some limited triage decisions and direct patients to other services such as pharmacy first when they do not need to see a GP.
At the previous inspection we identified that staff could not always access information they needed to be able to fulfil their duties. Some of this information was paper-based and not available on site during our inspection and some was stored digitally in ways that limited legitimate staff access. For example, the practice safeguarding register was stored on the safeguarding lead’s computer and could only be accessed by other staff when the lead was not using it. The caretaker provider had ensured that all staff were provided with smartcards and logins to enable them to access the information they required. The provider submitted no evidence to show they had reviewed information technology within the practice to reduce the need for paper-based record keeping and improve access to information.

New policies, systems and procedures had been developed in isolation by the provider and no provision had been made for the need to train staff to work within these systems or for staff to collaborate in designing systems based on what they had learned during the suspension period.

Following this inspection the provider arranged further meetings with the caretaker provider in order to learn more about the changes that had been made. They met with existing staff to discuss their current and proposed job roles, identify learning needs and devise personal development plans. However, this work was done too late in the suspension review process to demonstrate that training was embedded or any additional learning needs addressed to support a safe transition of services back to the provider.

In order to increase GP capacity, the provider proposed to employ locum doctors who would be exclusively based at a local practice half a mile away where additional clinical rooms were available, whilst building work was completed. This did not allow for sufficient supervision and oversight of locum doctors. It was also unclear what reception and waiting room facilities were available for patients at this other practice and the provider was unable to clarify whether use of the other practices reception team had been agreed, whether access to Naseby’s booking systems had been facilitated and who had clinical responsibility should a Naseby patient have a medical emergency whilst on the other site. This evidenced that the provider had not fully considered the implications of their plans or risk assessed them effectively. This did not provide assurance of a systematic approach to operational risk management.
 

At our previous inspection we found that the provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The provider did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. We identified multiple patients with potential missed diagnoses. This meant patients would not receive regular review which gives them the opportunity to ensure their condition is well-managed and to reduce the likelihood of complications.

During this inspection, the provider described their plan to ensure that people with potential missed diagnoses were identified and reviewed appropriately. Based on the provider’s plan, the necessary clinical searches to identify affected patients would not be completed before our decision on the suspension. This meant the provider was unable to confirm the number of patients who may be at risk or to allocate appropriate time and resources to address these concerns. The provider had not sought access to this information from the caretaker provider in advance, meaning decisions were not informed by current data. The system for identifying and managing possible missed diagnoses was not coherent, embedded or effective, and staff had not been trained in its use.

We were therefore not assured that risks relating to potential missed diagnoses would be reduced.
 

The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

During this inspection there were some improvements insofar as the plan to recruit pharmacists to undertake structured medication reviews, high-risk drug monitoring and long-term condition reviews. This was offset by the fact that one of the proposed pharmacists did not have any experience of working in primary care and neither had specialist training in asthma or diabetes. The proposed job plan for these pharmacists was extensive and would create an unusually large workload which would reduce the ability to manage these patient groups in a timely way.

After the inspection, the provider refined this plan and advised that they intended to recruit 4 part-time pharmacists who had appropriate skills and experience. The job plan for these staff had been reduced. However, this information was submitted very close to the expiry date of the suspension and did not include a plan for covering any notice or induction periods for the new staff nor was clear whether these staff were permanent or temporary therefore it did not provide assurances.

Based on the evidence supplied, the provider could not demonstrate that they had safe, effective systems embedded systems that would provide a smooth and swift pathway for patients who required regular monitoring and review to achieve the best possible control of their condition.

The provider had increased staffing and specifically GP clinical time in developing dedicated long-term condition clinics. However, the operation of these clinics and the indications for booking patients into a GP-led clinic were unclear although it appeared to be for patients who required more than routine management. The impact on overall routine access had not been sufficiently mitigated meaning that whilst patients with long-term conditions may benefit from these changes, patients with other conditions may experience poorer service.

The GP partners had completed training in diabetes and asthma in order to address the concerns regarding competence identified by us at our last inspection. However, the Pitstop diabetes training program they completed is a foundational program and is not designed for healthcare practitioners who will be focusing on the more complex and difficult to manage cases, such as those booked into GP-led clinics.

The proposed plans did not fully explain how systems and processes applied to other long-term conditions which require regular monitoring such as patients with hypothyroidism (an underactive thyroid gland) would be managed.
 

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.