All inspections: Elmwood Medical Centre

We carried out an announced comprehensive inspection at Elmwood Medical Centre on 18 and 21 September 2023. Overall, the practice is rated as Good. It is rated as good for providing safe, effective and well-led services. Due to assurances we received from our review of information, we carried forward the rating of good from our previous inspection in January 2023 for the key question caring. We rated the practice requires improvement for providing a responsive service.

Following our previous inspection on 27 January 2023, the practice was rated inadequate overall and for the key questions safe and well-led. We rated the key questions effective and responsive as requires improvement and caring as good. The practice was placed into special measures. We carried out an unrated inspection on 26 June 2023 to check that the breaches of regulation had been addressed and found that most of them had been.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elmwood Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation and 3 best practice recommendations from our previous inspections in January and June 2023. We inspected the key questions safe, effective, responsive and well-led.

How we carried out the inspection.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

Conducting staff interviews using video conferencing.
Sending out staff questionnaires.
Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
Reviewing patient records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
A site visit.
Interviews with a representative from the Patient Participation Group
Interviews with representatives from 3 care homes that used the service.

Our findings

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 ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
The cervical screening rate remained below the 80% national target. Action was being taken to address this.
Most staff had not received an appraisal within the last year. Action plans were in place to address this.

However, we have continued to rate the practice as requires improvement for providing responsive services because:

All 4 indicators for patient satisfaction with access to appointments in the national GP patient survey were below the local and national averages and had continued to fall since our previous inspection in January 2023.
Repeat prescriptions were not always provided in a timely manner.

Whilst we found no breaches of regulations, the provider should:

Review systems to improve the timeliness to the issuing of repeat prescription requests.
Continue to review and improve their systems and processes to improve access to appointments. The CQC recognises the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by patients’ needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient national survey data or other sources of patient feedback.
Continue to embed into practice improvements to increase the cervical screening rate to the national target of 80%.
Carry out their action plan to provide staff with annual appraisals.

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

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

We carried out an announced focused inspection at Elmwood Medical Centre on 23 and 26 June 2023. The inspection was to ensure that the issues identified in the warning notices, served on 9 February 2023, for safe care and treatment and good governance had been addressed. This report only covers our findings in relation to the warning notices and is therefore not rated.

Following our previous inspection on 23 – 27 January 2023, the practice was rated inadequate overall and in safe and well-led. It was rated as requires improvement for effective and responsive and good for caring. The practice was placed into special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elmwood Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to review if appropriate action had been taken to address the issues identified in the warning notices.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

Conducting staff interviews using video conferencing.
Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
Reviewing patient records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
A short site visit.
CQC staff questionnaires.

Our findings

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 ongoing monitoring of data about services
information from the provider and other organisations.

We found that:

The issues previously identified in providing safe care and treatment had been addressed in part. We found the practice had addressed the following:

Recruitment policies and processes had been updated appropriately.
Systems for assuring infection prevention and control were in place.
Patients prescribed medicines that required monitoring or medicines used in the treatment of their long-term conditions had received effective monitoring.
Effective medicine reviews had been completed.
Processes to prevent the accidental turning off of vaccine fridges were in place.
Systems were in place to ensure the timeliness of the scanning and coding of letters received from secondary care.

However, there was still more work to do in the following areas:

Systems did not fully support the effective safeguarding of children and vulnerable adults.
All of the required risk assessments had only in part been completed and had not always been shared with staff.
A system of clinical supervision and audit was not in place for non-medical prescribers.

The issues previously identified in providing effective and responsive care had been addressed:

Patients with long-term conditions had been reviewed effectively and systems to follow up patients that had not complied with repeat requests were in place.
Patients who complained to the practice were informed of the Parliamentary and Health Service Ombudsman when they received an acknowledgement of their complaint.

The issues previously identified in providing well-led services had been addressed in part: We found the practice had addressed the following:

The provider was more visible within the practice and most staff felt listened to.
Governance arrangements and policies were not always up to date, lacked clarity or were not complied with.
Most staff felt safe to speak out and staff were aware of who the Freedom to Speak Up Guardian.
Staff morale had improved and where training needs had been identified support had been provided.
Lead roles had been identified within the practice.
The business continuity plan had been updated to reflect changes within the practice.
Systems were in place to ensure statutory notifications were forwarded to the CQC.

However, there was still more work to do in the following areas:

All of the identified risks identified at our previous inspection had not been fully assessed or mitigated.

We found there had been significant improvement in many areas of the warning notices served on 9 February 2023. However, there remained some areas that had not been addressed.

The provider must:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

We carried out an unannounced comprehensive inspection at Elmwood Medical Centre from 23-27 January 2023. Overall, the practice is rated as inadequate. We rated the practice as inadequate for providing a safe and well-led service, requires improvement for providing an effective and responsive service and good for providing a caring service.

Following our previous inspection on 5 March 2018, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elmwood Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in response to concerns shared with the CQC. It was a comprehensive inspection which looked at:

The key questions safe, effective, caring, responsive and well-led.

How we carried out the inspection

This inspection was an unannounced onsite inspection and included:

Conducting staff interviews.
Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
Reviewing patients’ records to identify issues and clarify actions taken by the provider.
Requesting evidence from the provider.
Staff feedback questionnaires.
Interviews with local care homes and a representative from the Patient Participation Group.

Our findings

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 ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We rated the practice as inadequate for providing a safe service because:

Systems did not fully support the safeguarding of children and vulnerable adults.
Assurances that staff employed by the Primary Care Network and working in the practice had been recruited in accordance with Regulations had not been gained.
Systems for assessing the immunisation status of non-clinical staff were not in place.
Risk assessments had not always been completed or shared with staff to assess and manage risks.
Findings from the practice’s infection control and prevention audits and risk assessments had not been acted on in a timely manner. Water temperatures had not been recorded in line with the legionella risk assessment since September 2022. Sharps bins were not always dated in line with national guidance.
Staff told us that staffing levels were not adequate to meet the demands of the service. Some staff expressed concerns that despite invites to training and support from the safeguarding lead for GoToDoc Ltd, they did not feel they had been adequately trained to carry out their lead roles in safeguarding.
Patients’ records were not always managed in line with current guidance.
There was a backlog in the summarising of notes and, the scanning and coding of hospital discharge letters.
A system of clinical supervision or peer review was not in place for non-clinical prescribers.
Patients prescribed high-risk medicines or patients prescribed medicines for their long-term conditions had not always received the required monitoring.

We rated the practice as requires improvement for providing an effective service because:

A representative of a care home expressed concern about a 2-month delay in providing their residents with flu vaccinations over the winter period.
The system in place to offer annual reviews to check the health and medicine needs for patients was not always effective.
Systems for following up on patients with undiagnosed diabetes were not always effective.
Patients with long-term conditions were not always reviewed to ensure their treatment was optimised in line with national guidance.
We found over 200 hospital letters waiting to be scanned and coded on the day of our onsite inspection.
Some staff told us they did not feel they had received adequate training during their induction to carry out their roles and that the training had been rushed. Staff expressed concerns about who would support and train new staff due to the loss of experienced staff.
Formal clinical supervision was not in place to support staff working in advanced roles. Oversight and supervision of long-term locum GPs was carried out mostly remotely.

We rated the practice as good for providing a caring service because:

Staff treated patients with kindness, respect and compassion and helped patients to be involved in decisions about care and treatment.

We rated the practice as requires improvement for providing a responsive service because:

Patients did not always receive the care they needed within a timely manner including flu immunisations for patients living in a care home.
The provider had not acted in line with their own complaints policy and informed patients they could take their complaint to the Parliamentary and Health Service Ombudsman (PHSO) if they were unhappy with the outcome of the investigation of their complaint.

We rated the practice as inadequate for providing a well-led service because:

The delivery of high-quality care was not assured by the leadership, governance or culture within the practice
Most staff told us that the provider was not visible and that they did not feel valued or listened to by the provider.
There was a plan in place to support transformation in the practice however, the impact of the actions did not align with what staff told us or patients’ responses. This had led to an ongoing reduction in the practice’s patient list size in contrast to the other practices in Buxton.
The provider told us there was a Freedom to Speak Up Guardian and this information had been shared with staff in various ways. However, 6 out of 7 staff members that returned CQC questionnaires to us told us they were unaware of this support meaning communication with staff had been ineffective. Some staff feared retribution for raising concerns.
Most staff told us that staff morale was very low due to high levels of stress and work overload. Most staff told us they did not feel respected, valued, supported or listened to by the provider.
Governance arrangements and policies were not always up to date, lacked clarity or not complied with. Some staff told us they were unsure of where to locate policies. The practice’s Business Continuity Plan had not been updated to reflect changes within the practice.
There were a lack of systems in place to provide appropriate onsite supervision of non-medical prescribers, agency staff and locum GPs increasing risks to patients.
Practice risk registers and action plans had been put in place however, they did not reflect all of the risks we identified as part of our inspection.
Required statutory notifications had not been forwarded to the CQC within a timely manner.

We found 2 breaches of regulations. The provider must:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

Take action to improve their cervical screening uptake rate which was below the national target of 80%.
Work with care homes to improve communication and support.
Continue to carry out improvements to manage the heating, maintenance and water temperature within the premises.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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 6 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 6 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.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

Letter from the Chief Inspector of General Practice

This practice is rated as good overall. (At the previous inspection undertaken in October 2014, the practice also received a good overall rating)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Elmwood Medical Centre on 5 March 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

There was a clear leadership structure and staff told us they felt well-supported by the partners and practice manager. We observed the positive impact this had in establishing a well-integrated practice team with low staff turnover and high morale.
GPs and practice staff worked effectively as a cohesive team and provided personalised and responsive care to their patients.
There was an emphasis on a patient centred approach in all aspects of the practice’s work. This was underpinned by the practice’s values.
Results from the 2017 national GP patient survey showed that the practice had performed either above or in line with local and national averages regarding patient experience. The results had increased in 19 of the 23 indicators since the last survey was undertaken in 2016.
The national GP survey showed that 88% of patients who responded would recommend the surgery to someone new to the area compared with the clinical commissioning group (CCG) average of 81% and the national average of 77%. This was reinforced by the Care Quality Commission (CQC) comment cards completed by patients prior to our inspection, which reflected that patients were highly satisfied with the care they had received.
The practice had a strategy and forward vision. They worked with their local CCG and practices to maximise improvements in primary care for local patients. For example, the practice were seeking a solution to NHS England’s requirementto ensure that patients had enhanced access to GP services, including appointments during evenings via an 8-8 service, and the provision of appointments at the weekend and bank holidays.
There was a focus on continuous learning and improvement at all levels of the organisation. Staff training records were up to date, and regular appraisals encouraged development at all levels.
The practice had an established quality improvement programme. This included a regular audit programme which demonstrated improvements in outcomes for patients.
We found that the procedure for checking medicines within the practice was not sufficiently robust and we discovered two items of medicines and consumables that had exceeded their expiry date.
The practice was able to demonstrate compliance with health and safety legislation. However, we observed one piece of broken equipment which had not been labelled or removed from a clinical room.
The practice encouraged and supported staff to report incidents, although we found that there were generally low levels of incident reporting in the practice. There was some scope to enhance investigations into incidents and to share learning earlier and more widely.

The areas where the provider should make improvements are:

Strengthen procedures to check for out of date medicines and consumables.
Review the process for investigating incidents and sharing learning from significant events with all team members.
Review the procedure for labelling and removing any broken equipment from clinical areas.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We inspected Elmwood Medical Centre on 20 October 2014. The practice operates from 7 Burlington Road, Buxton, Derbyshire SK17 9AY. This was a comprehensive inspection.

This practice has an overall rating of good.

Our key findings were as follows:

The service was safe in all areas. Staff understood their responsibilities to raise concerns and report accidents, incidents and near misses. Opportunities to learn from internal and external incidents were analysed and used to support improvement.
The service was effective. Elmwood Medical Centre had sound clinical systems in place to ensure effective service delivery. This included regular clinical meetings with recorded discussion and learning points. In addition the practice followed local and national guidelines and best practice such as National Institute for Health and Care Excellence (NICE) guidelines.
The service was caring. Data from the patient’s survey showed that patients rated the practice higher than others locally and nationally. For example patients spoke positively about their experiences of receiving care from their GP.
The service was responsive. The practice was open to considering alternative methods of meeting patient’s needs and ensuring that referrals were made to hospital or other services in a timely manner.
The service was well-led. There was a stated vision for the practice, and clear lines of accountability and leadership in place. Complaints and concerns were addressed and learning points were used by the staff to make improvements.

We saw areas of outstanding practice including:

The practice offered in-house acupuncture by one of the GP partners as part of its approach to pain management as part of the National Health Service provided.
The practice had developed their own risk assessment tool to identify which patients aged over 75 were most at risk of avoidable unplanned admissions. North Derbyshire clinical commissioning group (CCG) had expressed an interest in using the tool at other practices.

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

The provider should:

The provider should have an effective system to assess the risk of, prevent, detect and control the spread of health care associated infection and ensure that any risks are identified.

The provider should carry out a review of security at the practice and consider the risks to staff, patients, and resources.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Elmwood Medical Centre

All Inspections

18 and 21 September 2023

During a routine inspection

23 and 26 June 2023

During an inspection looking at part of the service

23 - 27 January 2023

During a routine inspection

5 March 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

20 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)