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The Matthews Practice Belgrave Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 April 2019

We carried out an announced comprehensive inspection at the Mathews Practice Belgrave on 16 March 2018. The practice was rated as requires improvement overall and was to remain in Special Measures until further improvements had been seen.

At our inspection on 16 March 2018 we found:

  • The practice was in the process of implementing a complex process of change management in order to make improvements and develop their service.
  • The practice had undergone a number of recent and significant changes to their senior management team. For example, GP partnership arrangements had changed because one of the GP partners had stepped down to become a salaried GP and a new Registered Manager had recently been appointed.
  • Practice governance arrangements needed to be fully embedded to ensure lasting and positive changes could be sustained within the practice.
  • Quality Outcomes Framework (QOF) data available on the day of inspection identified that the practice was failing in delivering adequate plans and pathways to mitigate risks and thoroughly risk assess the management of long term conditions. Subsequent QOF data from 2017/18 showed some improvement whereby the practice achieved 519.54 out of 559 points.

Requirement notices were issued because:

  • Patient Group Directives (PGD’s) needed attention to ensure that they were being managed correctly.
  • A number of confidential patient records were being held in an area used for occasional external visitor meetings. Although these records were stored behind a security coded door we found some of the drawers to be unlocked on the day of inspection.
  • The practice had a sepsis strategy in place however on the day of inspection a member non-clinical staff we spoke to was not aware of the management of sepsis should a patient present with symptoms.

This inspection, was an announced comprehensive inspection, which was carried out on 9 January 2019. This report covers our findings in relation to the practice meeting the requirements of the requirement notices and also additional improvements made since our last 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 on-going monitoring of data about services.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and for all population groups.

We found that:

  • The practice had worked through a substantial process of change management in order to make improvements and develop their service in collaboration with the local Clinical Commissioning Group (CCG) and the Royal College of General Practitioners (RCGP).
  • The practice had undergone a number of recent and significant leadership changes and was nine days into a new contract as a single handed provider.
  • New practice governance arrangements had been implemented to develop lasting and positive changes within the practice.
  • Quality outcomes framework data available on the day of inspection identified that the practice was delivering plans and pathways to mitigate risks and assess the management of long term conditions.

  • A new policy and process was in place to ensure that Patient Group Directives (PGD’s) were being managed correctly.
  • Confidential patient records were being safely stored behind a security coded door.
  • The practice had a sepsis strategy in place and all staff that we spoke to were aware of the management of sepsis should a patient present with symptoms.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was managed promoted the delivery of quality care.

Whilst we found no breaches of regulations, the provider

should

:

  • Improve the cascade and management of safety alerts.
  • Amend their staff vaccination protocol to include Varicella (chicken pox) and MMR (measles, mumps and rubella) in order to be in accordance with current Public Health England (PHE) guidance.
  • Improve patient access to services.
  • Review and improve patient satisfaction with regard to their involvement in decisions about their care and treatment and their access to appointments.

This practice had met the requirement notices issued in March 2018 and has been taken out of special measures.

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

Professor Steve Field

CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Caring

Requires improvement

Responsive

Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement