Wilmslow Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wilmslow Road Surgery on 13 December 2017. We had previously inspected the service in April 2017 where we identified significant concerns, the practice was rated inadequate and placed into special measures. We issued two warning notices for regulation 12 Safe care and treatment and regulation 17 Good governance. In September 2017 we carried out a follow up inspection to review the action the practice had taken in response to the warning notices we issued. That was not a full inspection and did not change the practice rating.

This inspection, on 13 December 2017 was a full comprehensive rating inspection. It was carried out to confirm the practice had implemented their plan to meet the legal requirements in relation to the breaches in regulations we identified at the inspection on 26 April 2017.

Overall the practice is now rated as requires improvement.

Since the last inspection visit in September 2017 we found the practice had continued to work to sustain and implement their action plan to improve the service they provided.

• The practice held weekly team meetings for all staff where permanent agenda items were discussed. The areas discussed each week included significant events, complaints, safeguarding and changes to guidance.
• The system in place to report, investigate and respond to significant events was comprehensive and there was good evidence the provider complied with the Duty of Candour.
• The practice had reviewed its systems to ensure patients were safeguarded from abuse. Staff were trained and there were systems to monitor patients identified at risk of abuse. A carer’s register was available.
• The practice had reviewed their systems to ensure patient pathology results were reviewed and responded to quickly. They also ensured that safe systems were in place for patients referred on the two week pathway and those prescribed high risk medicines. There were care plans in place for vulnerable patients and for those assessed as frail.
• A full range of emergency medicines was now available, and regular monitoring checks were undertaken of these, the defibrillator and oxygen. Systems to log and monitor prescription paper were also now in place.
• Evidence available demonstrated staff were recruited appropriately. Systems to appraise and develop staff skills and abilities had been implemented and feedback from those staff we spoke to felt this was positive and supportive.
• The practice had undergone a comprehensive refurbishment so that it provided a clean bright environment with a comfortable waiting area for patients.
• Comprehensive risk assessments for fire safety and legionella were up to date. Action had been taken to ensure the building minimised the risks associated with Legionella bacteria and improvements had been made in the fire safety arrangements at the practice.
• Governance arrangements to monitor and review the service provided were implemented and these were underpinned with a five year business plan and strategy.
• A comprehensive range of policies and procedures were available which included the Duty of Candour or Being Open policy, Consent and the Mental Capacity Act.
• The practice provided open surgeries four mornings each week.
• Patient feedback from the GP patient survey published in July 2017 showed a deterioration from the previous year results. Patient responses indicated there was a higher level of dissatisfaction with GP and nursing care interactions and access to the service. The practice had taken action to improve patient satisfaction but further work was required.
• The practice website had been updated and this provided up to date information for patients.

However, there were also areas of practice where the provider needs to make improvements. 

The provider should:

• Continue to promote and encourage patient uptake of cervical screening.
• Consult with patients to implement effective improvements to increase patient satisfaction with access to the service and the quality of care and treatment provided by clinicians.
• Improve the quality of documentation, so that all clinical audits are recorded to the same standard.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wilmslow Road Surgery on 25 April 2017. The overall rating for the practice was inadequate. The full comprehensive report on the April 2017 inspection can be found by selecting the ‘all reports’ link for Wilmslow Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 6 September 2017 to confirm that the practice had carried out their plan to meet the Warning Notices in relation to the breaches in regulations that we identified in our previous inspection on 25 April 2017. This report covers our findings in relation to those Warning Notices. The evidence provided during this inspection demonstrated improvements had been made and the provider had met the requirements of the warning notices.

Our key findings were as follows:

• At the previous inspection we found 119 patient pathology laboratory reports dating back to 15 March 2017, with no evidence of action on the patient record system. At this inspection we found a system to monitor and respond appropriately to pathology laboratory reports had been established.
• The previous inspection identified that there was no system in place to collectively view patients with a safeguarding plan in place or those assessed as at risk from abuse. At this inspection we found a safeguarding protocol had been developed and a safeguarding register was maintained.
• During the inspection in April 2017 we found there were no systems in place to monitor those patients referred onto the two week referral pathway to secondary care. At this inspection we found the surgery had established a protocol for managing two week referrals with a weekly search being carried out to identify and follow up patients who did not attend their hospital appointments.
• At the previous inspection in April 2017 we found that there were no systems in place to monitor patients prescribed the high risk medicine Methotrexate a disease modifying anti-rheumatic drug (DMARD). At this inspection we found a protocol had been developed and a register of DMARDs was maintained.
• At the inspection in April 2017 we found action plans had not been implemented in response to fire and legionella risk assessments and identified that not all staff had received appropriate training. At this inspection we found that action plans had been developed in response to the recommendations made following the legionella and fire risk assessments and training was planned for lead staff.
• Our inspection in April 2017 identified there were no systems in place to ensure GPs responded to changes in NICE guidance and alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). At this inspection we found a record was maintained by the practice manager. All notifications were received by the practice manager and disseminated to the GPs. These were then stored on the practice shared drive and alerts were discussed at weekly practice meetings.
• During the inspection in April 2017 we found there were no systems in place to check the defibrillator and oxygen. At this inspection we found these checks were being carried out and included a record of the expiry dates for the oxygen cylinders.
• At the inspection in April 2017 we found staff did not have access to minutes of meetings in the practice manager’s absence. At this inspection we found meeting minutes were saved to the practice shared drive and all staff told us they were able to access them.
• There was no policy relating to the Duty of Candour, Consent and the Mental Capacity Act 2005 and where policies were in place there were no systems in place to ensure staff had access to them. At this inspection we saw copies of these policies and staff were able to show us how they could be accessed.
• Our inspection in April 2017 identified that not all necessary recruitment records for all staff had been conducted. Self-employed staff did not have a record of their employment status or references. At this inspection we found staff files contained all the required information.
• Our previous inspection in April 2017 identified records monitoring the use and traceability of prescription paper in the practice were not available. We found at this inspection that a new procedure had been introduced to record and monitor these prescriptions.
• At the inspection in April 2017 it was identified that care plan templates were not available. Where records showed that a patient had a care plan in place we were told that this was following a discussion with the patient and this was not written down. At this inspection we found a generic template had been developed as well as templates for patients aged over 75 years and those patients with a long term health condition. Plans were signed by the patient and scanned into the patients electronic notes.
• At the last inspection we found there was no system in place to ensure the practice website was regularly updated. At this inspection we found that nominated members of staff were authorised to review and amend information on the practice website and this was done on a regular basis.

This inspection was carried out to check that the practice had addressed the Warning Notices issued following the inspection in April 2017. Ratings will not be affected by this inspection. A comprehensive inspection will be carried out soon where the ratings will be reviewed. The practice remains in special measures at this time.

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 Wilmslow Road Surgery on the 14 April 2016. The overall rating for the practice was requires improvement, with key question Safe rated as inadequate, and Responsive and Well led rated as requires improvement. We issued three requirement notices for breaches of regulation and the practice submitted an action plan detailing how they intended to improve the service they provided. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Wilmslow Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 25 April 2017. Overall the practice is now rated as Inadequate.

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

• Since the last inspection the practice had improved the system for reporting and recording significant events and ensuring all staff were made aware of any learning and improvement from incidents.
• Actions undertaken by the practice to ensure health care risks for patients were minimised were inadequate. For example safeguarding registers and carer’s registers were not available.
• Systems to ensure patient pathology results were checked in a timely manner were not implemented, recorded care plans were not available and checks to monitor patients referred on the two week pathway were reactive.
• Some improvement had been made to recruitment checks since the last inspection. Recruitment records included Disclosure and Barring Service checks (DBS) for staff employed at the practice. However we observed that one employee’s recruitment file was missing information about their employment status and professional and character references.
• Some improvements had been made in the environment at Wilmslow Road, however further refurbishment was required.
• Risk assessments for fire safety at both the practice main location (Wilmslow Road) and the branch location in Sale had been undertaken but no action had been taken to address the key risks areas identified. A Legionella risk assessment for Wilmslow Road had been undertaken but no action had been implemented in response to the areas identified.
• Governance arrangements to monitor and review the service provided were not supported by clear objectives and actions plans. This had resulted in gaps in service delivery and performance.
• Some policies including the Duty of Candour or (Being Open policy), Consent and the Mental Capacity Act were not available and the complaints policy was available upon request and was not in a user friendly format.
• Staff confirmed they attended weekly team meetings which they found useful.
• The practice had reviewed its patient access to appointments and provided open surgeries four mornings each week.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice website needed updating.

The areas where the provider must make improvements are:

• Implement action to mitigate any risks to patients and to ensure care and treatment is provided in a safe way. This includes:
  • Ensuring patient pathology laboratory results are responded to in a timely manner,
  • Ensuring the practice safeguarding leads have oversight and knowledge of children and young people with a child protection plan in place or designated at ‘risk’.
  • Ensuring there are appropriate emergency medicines available to respond quickly and effectively to medical emergencies such as severe asthma, pain, and nausea.
  • Ensuring patients prescribed high risk medicines such as disease-modifying anti-rheumatic drugs (DMARDs have received the correct healthcare monitoring
  • Ensuring the written care plans are maintained and copies provided to patients.
• Implement immediate action to improve the practice environment by undertaking a planned programme of improvement to minimise the identified risks in the fire and Legionella risk assessments.
• Implement comprehensive systems of governance to monitor and review the practice performance and implement strategies to improve, including:
  • Ensuring policy and procedures are available including The Duty of Candour, Consent and the Mental Capacity Act.
  • Implementing systems to monitor actions taken in response to NICE guidance and updates from the Medicines & Healthcare products Regulatory Agency (MHRA).
  • Ensuring the complaints policy is readily available to patients in a readable format.
  • Ensure systems to monitor patients two week secondary care referrals are proactive and systems to monitor patients on high risk medicines such as DMARDS are implemented.
  • Ensure all staff have access to essential information including team meeting minutes, guidance and alerts.

In addition the provider should:

• Improve systems to demonstrate the receipt of all the necessary pre-employment checks for all staff including agency /self-employed staff.
• Take proactive action to improve cancer screening of patients including cytology
• Implement a system of regular checks for the oxygen and the practice defibrillator.
• Improve the monitoring of all prescription paper used at the practice.
• Implement a planned programme of refurbishment.
• Develop a carer’s list in order to support patients who are also carers.
• Update the practice website to reflect the actual services provided including changes in the appointment system, staffing and medical students.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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