Sherwood Rise Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sherwood Rise Medical Centre on 22 and 30 August 2017. The overall rating for the practice was inadequate, and it was placed into special measures. Two warning notices were issued to the provider in response to identified breaches in regulations. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Sherwood Rise Medical Centre on our website at www.cqc.org.uk.

The overall rating of inadequate will remain unchanged until we undertake a full comprehensive inspection of the practice within the six months of the publication date of the report from August 2017.

This inspection was an announced focused inspection carried out on 8 January 2018 to confirm that the practice had taken the required action to meet the legal requirements in relation to the breaches in regulations set out in the warning notices issued to the provider.

The warning notices were issued in respect of regulations related to safe care and treatment, and good governance. Specifically, the provider did not have an effective system in place to review and act on alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA); and in addition, the standards of record keeping were found to contain inaccurate or incomplete entries, and were not always kept up to date.

Our key findings were as follows:

• The practice had complied with the warning notices that we issued and had taken action to ensure they met with legal requirements.
• The process in place to review and act on MHRA alerts had improved significantly. A comprehensive alert log was maintained to summarise the receipt of incoming alerts, the follow up actions taken, and the outcomes this produced.
• We observed that alerts were reviewed by clinicians and supported by audits where necessary. Entries on individual patient records summarised any actions taken in response to the alert.
• The standards of record keeping had improved. We observed that entries into patient records were being recorded in greater detail. Entries were mostly made contemporaneously. If the notes were recorded retrospectively, this was clearly indicated within the entry.
• The practice had sought help to respond to our previous findings and we saw evidence of joint working with their Clinical Commissioning Group (CCG), the Local Medical Committee (LMC), NHS England and external consultants.

However, the provider should continue to make improvements in the following area:

• Review the arrangements to follow up on any actions that may be indicated when adverse test results have been received.
• Ensure that when a medicine review has been documented in a patient’s notes, the review has been completed in line with recommended guidance.  

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sherwood Rise Medical Centre on 1 December 2016. The overall rating for the practice was requires improvement. The service was rated as inadequate for being well-led, requires improvement for safe, and good for effective, caring and responsive. A warning notice was also issued following this inspection to ensure action was taken to meet the legal requirements within our regulations.

The warning notice was issued in response to limited governance arrangements to support the delivery of care including a lack of systems and processes to identify, assess and monitor risk; the ability to respond to specific clinical emergencies, or those risks associated with fire and legionella; and a number of policies contained information which was not relevant to the practice including naming staff who worked for another practice as having a lead responsibility.

We undertook a focused inspection on 19 April 2017 to check the practice was compliant with the warning notice. We were assured that the practice was compliant with the warning notice at this visit.

The full comprehensive report from the December 2016 inspection, and the focused inspection on April 2017, can be found by selecting the ‘all reports’ link for Sherwood Rise Medical Centre on our website at www.cqc.org.uk.

As the inspection in December 2016 rated the service as inadequate for one of the five key questions (well-led), it has to be re-inspected within six months of the publication of the report. This inspection was undertaken as an announced comprehensive inspection over two days on 22 and 30 August 2017. Overall the practice is now rated as inadequate.

Our key findings were as follows:

• We found that the service remained inadequate for well-led. The practice had a leadership structure in place, however, there was insufficient clinical leadership, limited formal governance arrangements and clinical oversight of processes needed to be strengthened.
• During our inspection, we found that patient care records were not always updated on the day of a consultation taking place with a GP. This created a risk for patients, and for other clinicians, as care records may not have been factually accurate or represent the actual care and treatment of patients.
• We observed that a number of entries for patient consultations had been recorded under the wrong dates, and that records were not always clear. There was evidence that some requests had not been followed up, for example in relation to information contained within hospital letters.
• Patients were at risk of harm because some systems and processes were not in place to keep them safe. For example the practice did not have effective procedures in place to deal with alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA) or alerts related to patient safety. We found that some alerts had not been reviewed, or in other cases, that searches were ineffective and had failed to identify all the relevant patients who may be affected to ensure they could be recalled.
• Staff told us that they assessed patients’ needs and delivered care in line with current evidence based guidance. However, there had been no clinical meetings held since March 2017 to ensure a co-ordinated response when, for example, new or updated guidance was issued.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Most patients said they were treated with compassion, dignity and respect and they were involved in decisions about their treatment. However, data from the latest national GP patient survey showed that some areas of performance had declined since the previous survey 12 months earlier. Overall, outcomes were in line with, or lower than, local and national averages.
• Information about services and how to complain was available and easy to understand, although options (for example, making the complaint directly to NHS England rather than the practice) were not always clearly described for patients. Improvements were made to the quality of care as a result of complaints and concerns.
• Staff were supported to access training to provide them with the skills and knowledge to deliver care and treatment.
• Patients said they were generally able to access urgent appointments but national GP patient surveys results showed a decrease in satisfaction in terms of getting through to the practice by telephone, and with the practice’s opening times.
• The practice had the facilities and equipment to treat patients and meet their needs. A refurbishment plan had been produced to address areas of the premises which had been identified for improvement, but this was still awaiting financial support.
• Medicines were safely stored and were all within their expiry date. However, the management of prescriptions within the practice needed some review to ensure that new stock was logged and signed for.
• Patient Group Directions (PGDs) to legally authorise a locum nurse to administer medicines, for example vaccines, had not been completed correctly and were therefore not valid.
• Staff told us that they felt supported by management and had regular team meetings. New staff received an induction and support, and all staff received regular appraisals.
• The practice sought feedback from staff and patients, such as performing their own patient survey, and produced an action plan to address any issues that were identified.
• A range of policies and procedures were in place to govern activity within the practice. However, we saw evidence that these were not always adhered to in practice.

Importantly, the provider must make improvements to the following areas of practice:

• Ensure care and treatment is provided in a safe way to patients, for example, by reviewing all relevant patient safety alerts, including those issued from the Medicines and Healthcare products Regulatory Agency (MHRA), and taking timely and appropriate follow up actions.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, by ensuring patient records are complete, legible, accurate and up to date. This includes contemporaneous entries into records which accurately reflect where and when the consultation had taken place.

The areas of practice where the provider should make improvements are:

• Address the issues highlighted in the national GP survey in order to improve patient satisfaction, including those in relation to difficulties in accessing appointments, and interactions with practice staff.
• Improve the identification of carers in order to provide them with appropriate support.
• Review the practice complaints procedure to ensure it fully reflects contractual obligations for GPs in England.
• Review the process in place for Practice Group Directions to ensure that they are correctly authorised for all staff that are required to use them.
• Improve the uptake of annual learning disability health checks.
• Review systems to keep clinical staff up to date with national and local guidance.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sherwood Rise Medical Centre on 1 December 2016. The overall rating for the practice was requires improvement; the practice was rated as requires improvement for providing safe services, good for providing effective, caring and responsive services and inadequate for providing well-led services. The full comprehensive report from December 2016 can be found by selecting the ‘all reports’ link for Sherwood Rise Medical Centre on our website at www.cqc.org.uk.

The overall rating of requires improvement will remain unchanged until we undertake a further full comprehensive inspection of the practice within the six months of the publication date of the report from December 2016.

This inspection was a focused inspection carried out on 19 April 2017 to confirm that the practice had taken the required action to meet the legal requirements in relation to the breaches in regulation set out in a warning notice issued to the provider. The warning notice was issued in respect of a breach of a regulation related to good governance; specifically the provider did not have effective systems in place to assess, record and monitor risks to the health and safety of service users. They had failed to identify the risks associated with not stocking some emergency medicines. Where risks had been identified, appropriate action to mitigate risk had not been taken or recorded for example in relation to fire and legionella. Policies and procedures were not always relevant to the practice and did not always reflect processes in place.

Our key findings were as follows:

• The practice had complied with the warning notice we issued and had taken the action needed to comply with legal requirements.
• Policies and procedures had been updated to ensure information was specific to the practice
• Measures were in place to mitigate identified risks in respect of legionella.
• A fire risk assessment had been undertaken in December 2016 and was supported by a comprehensive action plan.
• A review of the practice’s emergency medicines had been undertaken to ensure the practice could respond to clinical emergencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sherwood Rise Medical Centre on 11 November 2014. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Sherwood Rise Medical Centre on our website at www.cqc.org.uk.

We did a follow up inspection of the practice on 21 September 2015. This inspection did not result in any changes to the rating.

This inspection was an announced comprehensive inspection on 1 December 2016. Overall the practice remains 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. However, reviews and investigations were not always sufficiently detailed to ensure events did not re-occur.
• Some risks to patients were assessed and managed; however, the practice was not operating effective systems to ensure they had assessed all identifiable risks. For example, they had not assessed the risk of not having medicines to respond to specific clinical emergencies or those associated with fire and they had not yet taken actions identified as necessary to prevent legionella.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff were supported to access training to provide them with the skills and knowledge to deliver effective care and treatment.
• Data showed that patient outcomes were in line with local and national averages and evidence demonstrated the practice had made improvements to the level of care provided to their patients.
• The practice had participated in a city wide practice specific objective related to self-harm and suicide attempts. Following the review the practice now ran weekly searches of their patient record system to identify any patients who had been read coded with self-harm or suicide attempts to ensure these patients were added to a register to be reviewed and assessed for intervention by the GPs once a week. The practice met with other local GP practices to discuss best practice.
• The majority of patients said they were treated with compassion, dignity and respect and they were involved in decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they were generally able to access urgent appointments but some patients noted that there could be a long wait to be seen by the GP.
• The practice had the facilities and equipment to treat patients and meet their needs. There was a refurbishment plan in place to address areas of the premises which had been identified for improvement.
• There was a leadership structure in place and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• A range of policies and procedures were in place to govern activity within the practice. Although all policies had been reviewed in 2015, a number of policies contained information which was not relevant to the practice including naming staff who worked for another practice as leads in certain areas.
• The provider had not made sufficient improvements to governance and oversight and there were still areas presenting risks to patients which had not been addressed following our previous inspection in November 2014.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure that effective systems and processes are in place to identify, assess and mitigate risks related to the health, welfare and safety of service users and others by;
• Taking action to mitigate risks identified (for example in relation to legionella and fire) and ensuring all risks are assessed (for example those relating to emergency medicines and equipment).
• Ensuring policies and procedures are correct, relevant to the practice and reflect the processes in place.

The areas where the provider should make improvement are:

• Improve the recording and management of significant events to ensure reviews and follow ups are documented.
• Improve the systems for the management of complaints to ensure documentation is well ordered.
• Review the business continuity plan
• Continue to promote and increase uptake of childhood immunisations
• Improve the identification of carers to provide them with support and advice
• Take steps to improve confidentiality in the reception area.
• Continue to review the availability of appointments to address the patient feedback on delays in seeing a GP.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice