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Inspection carried out on 29 October 2019

During an inspection looking at part of the service

This inspection was a carried out in response to our findings during our on-going monitoring of the practice. The inspection was an announced focussed inspection, which we undertook on 29 October 2019, under Section 60 of the Health and Social Care Act 2008. This report covers our findings in relation to the effective, responsive and well-led key questions. The ratings for the safe and caring key questions will be carried through from the previous inspection on 13 September 2017, when the practice was rated as good overall and in the safe, effective, caring and well-led key question. The responsive key question was rated as requires improvement.

At this inspection, the practice was rated requires improvement in effective and good in the responsive and well led key questions. Three of the six population groups were rated good. Families, children and young people, people with long-term conditions and working age people were all rated requires improvement.

The reports of all the previous inspections of Conway PMS can be found by selecting the ‘all reports’ link for Conway PMS on our website at www.cqc.org.uk.

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 and the public.

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

  • The practice is below the CCG and national target in several 2018/19 QOF performance indicators; namely, families, children and young people, People with long-term conditions and working age people. The practice had identified these areas and had a plan to improve their performance but was not yet able to demonstrate improved outcomes.
  • The practice was unable to demonstrate that it always monitored and obtained consent appropriately.

We rated the practice as good for providing responsive services because:

  • Feedback from patients was acted upon and as a result, extended opening hours from 7am have been introduced on a long-term basis, as well as a new telephone system and online booking feature.
  • The practice actively sought input from external organisations and charities to improve services offered.
  • The practice actively offered patient choice with regards to care and treatment options. All nine of the patients interviewed stated they felt involved in the decisions made at the practice.

We rated the practice as good for providing well-led services because:

  • The practice had been responsive to feedback from our previous inspection and had addressed all our findings.
  • Governance of the practice promoted the delivery of high-quality and person-centred care, supported learning and innovation, and promoted an open and fair culture.
  • Staff understood the practice’s vision, values and strategy, and their role in achieving them.
  • Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care.

There were areas were the practice should make improvements:

  • Improve the process in place for the recording and monitoring of patient consent.
  • Continue to take steps to improve cervical cancer screening and childhood immunisation uptake.
  • Improve patient satisfaction with booking appointments further into the future.
  • Improve the process in place for reception staff knowing which type of appointments to book.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 13 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of Conway PMS on 2 February 2016. The overall rating was inadequate and the practice was placed in special measures.

We then carried out a follow up announced comprehensive inspection on 13 December 2016. We found that insufficient improvements had been made and the overall rating for the practice remained as inadequate. The practice remained in special measures for a further period.

The full comprehensive reports for both these inspections can be found by selecting the ‘all reports’ link for Conway PMS on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive follow up inspection carried out on 13 September 2017 to check that the provider had made all necessary improvements to meet the required regulations. The benefits of the changes and additions made to the management and leadership team within the practice were evident from the significant improvements made. Overall the practice is now rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had systems in place to minimise risks to patient safety.
  • The most recent data for the Quality and Outcomes Framework showed that most patient outcomes were comparable with local and national averages.
  • Childhood immunisation rates were slightly below the national target rate.
  • Staff were aware of and had access to current evidence based guidance.
  • Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey and feedback from people we spoke to showed that patients were treated with dignity and respect and felt they were involved in decisions about their care and treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they sometimes found it difficult to make an appointment with a GP. Patient satisfaction rates from the latest GP patient survey were below average for indictors regarding access to GP appointments. However, urgent appointments were usually available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

There were areas of practice where the provider should make improvements:

  • The provider should continue to monitor patient satisfaction with regards to access to appointments, and implement improvements as required.
  • The provider should continue to monitor uptake rates for childhood immunisation and national screening programmes and implement strategies to improve uptake rates as required.

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

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 13 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Conway PMS’ main and branch sites on 2 February 2016. During that visit our key findings were as follows:

  • Significant event recording needed improvement.

  • Systems in place to address risks were not implemented well enough to keep patients safe.

  • Clinical outcomes and patient satisfaction were low across several areas.

  • Consent had not always been appropriately recorded.

  • There were several instances where patient confidentiality was not maintained.

  • Patient information was not always available, and not all policies were fit for purpose.

  • Access to appointments was difficult and we had concerns regarding staffing levels.

  • Governance and leadership arrangements did not support the delivery of good care.

The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Conway PMS on our website at www.cqc.org.uk. Practices placed in special measures are inspected again within six months of the publication of their inspection report. The provider submitted an action plan to us to tell us what they would do to make improvements. We undertook this inspection to check that they had followed their plan, and to confirm that they had met the legal requirements.

This inspection, conducted as an announced comprehensive inspection of both sites on 13 December 2016, was undertaken following the period of special measures. Overall the practice is now rated as inadequate. Our key findings across all the areas we inspected in December 2016 were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses; however, the system for recording and discussing significant events was not formalised. This was highlighted at our last inspection.

  • Data showed that several patient outcomes remained below local and national averages in relation to the Quality and Outcomes Framework. Although some audits had been carried out these were initiated by the Clinical Commissioning Group. We saw no evidence of an internal audit plan.

  • Published data from the national GP patient survey showed that although patients had confidence in the GPs, the service was rated below average for several aspects of care and access. Performance had declined in some areas since the previous year and the provider was unable to demonstrate if any changes they implemented had had a positive impact.

  • Large amounts of patient-identifiable information had not been stored securely, an area of concern highlighted at our last inspection.

  • Improvements were made to the quality of care as a result of complaints.

  • The process for seeking consent had been improved since our last inspection.

  • The provider had updated several policies; however, some policies did not reflect the way the practice was operating.

  • The leadership structure was not well-defined and there were deficiencies in the governance of the service.

  • Staff felt supported and valued by the practice’s leaders. Staff had been trained to provide them with the skills, knowledge and experience to deliver care and treatment.

  • The practice sought feedback from staff and patients, which it acted on.

There are areas where the provider needs to make improvements. Importantly, they must:

  • Ensure records are maintained securely at all times in respect of service users.

  • Ensure effective and sustainable clinical governance systems and processes are implemented to assess, monitor and improve the quality and safety of the services provided, and implement an effective strategy to ensure the delivery of good quality care.

  • Implement actions to respond appropriately to patient feedback.

  • Ensure there are appropriate policies to enable staff to carry out their roles, and ensure these policies are being followed.

  • Assess, monitor, manage and mitigate the risks to the health and safety of service users and others that may be at risk.

In addition the provider should:

  • Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

  • Review the need to provide modesty screens or curtains for patients in consulting and treatment rooms.

This service was placed in special measures in September 2016. Insufficient improvements have been made such that there remains a rating of inadequate for several key questions (safe, effective, caring, responsive and well-led). Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 2 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Conway PMS on 2 February 2016. We inspected the main site in Plumstead and the branch surgery in Welling. Overall the practice is rated as inadequate.

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

  • There was a system in place for reporting, recording, investigating and learning from significant events. We saw one instance where an incident had not been reported. 
  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. This was in relation to fire safety, infection control, medicines management, training, recruitment, and the administration of vaccines by nurses. Some of these issues were addressed after the inspection.

  • Data showed patient outcomes were low in several areas in comparison to national averages.  Consent was not always recorded appropriately.

  • The majority of patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment; however we observed several instances where patients’ confidentiality was not maintained. The national GP patient survey results showed the practice was rated as being average for consultations with GPs and nurses.
  • Patient information and information about services was not always available.
  • Patients said they were not always able to make an appointment with a named GP and that there was limited continuity of care. Patients did not always have access to a GP. Urgent appointments were available the same day but non-clinical staff told us they assessed whether patients were in genuine need of urgent care.
  • The national GP patient survey results showed the practice was rated below local and national averages for some aspects of access to care.
  • There was a leadership structure and staff felt supported by management; however, governance and leadership arrangements did not support the delivery of good quality care.

  • The practice sought feedback from staff and patients; however, actions taken were not sufficient to make improvements to patient satisfaction.

The areas where the provider must make improvements are:

  • Ensure annual fire safety training and fire drills are completed, medicines are managed in line with current guidelines and all staff complete training at appropriate intervals.

  • Ensure nurses are working to up-to-date Patient Group Directions for the administration of vaccines, policies are reviewed and updated, and all staff are kept aware of and have access to practice policies.

  • Ensure patient confidentiality is maintained at all times and patients’ records are stored securely.

  • Ensure all issues identified in relation to infection control processes are addressed and improved.

In addition the provider should:

  • Ensure consent is always appropriately recorded and staff undertake mental capacity training.

  • Ensure recruitment procedures include two references for all newly recruited staff, in accordance with the practice’s recruitment policy.

  • Improve arrangements to address identified risks.

  • Ensure homeless patients are able to register and access continuity of care at the practice.

  • Ensure all staff are clear on the chaperone procedure.
  • Improve the process to ensure patients’ need for urgent care is assessed by clinical staff.

  • Ensure it continually monitors patient feedback and any areas identified for improvement are acted on.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice