Archived: Littletown Family Medical Practice

We inspected Littletown Family Medical Practice, 53 Manchester Road, Oldham OL8 4LR on 12 February 2019 as part of our inspection programme. The practice was given an overall rating of inadequate with the following key question ratings:

Safe – Inadequate

Effective – Requires improvement

Caring – Requires improvement

Responsive – Requires improvement

Well-led – Inadequate.

Requirement notices were issued in respect of breaches of Regulation 10 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (dignity and respect) and Regulation 16 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (receiving and acting on complaints). A warning notice was issued in respect of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance).

Following being placed into special measures the practice went through a period of uncertainty. This included one of the two long-term partners formally leaving the partnership.

On 3 July 2019 we carried out a follow-up inspection to check the requirements of the Regulation 17 warning notice had been met. At that stage, although we saw some improvements had started to be made, further work was required.

This inspection was carried out on 23 October 2019. This was a full follow up inspection carried out six months after the report placing the practice into special measures was published.

At this inspection we found that improvements had been made under each of the key questions and all the requirements of the requirement notices and warning notice had been met. The practice is now rated as good overall. All key questions are rated good. The population group working age people (including those recently retired and students) is requires improvement due to cervical screening data, and all other population groups are rated as good.

At this inspection we found:

• The practice had changed the use of two clinical consultation rooms to ensure the privacy of patients.
• The practice had implemented a new complaints procedure. We saw that all complaints were recorded, investigated, discussed and appropriately responded to. Reviews of complaints also took place.
• The arrangements for managing risks had improved. For example, the fire policy was now practice specific and actions required following a fire risk assessment had been implemented. There was a greater understanding of the infection control audit process and required improvements were made and monitored, and a cold chain protocol was put in place and monitored.
• The process for managing significant events had improved, with all significant events being documented, discussed and investigated, with learning taking place when required. Significant events were reviewed in a timely manner.
• Policies had been updated to ensure they were personalised to the practice and being followed.
• The training programme had been overhauled. A new system of recording training had been implemented and staff had completed training as required. The practice had a mixture of on-line and face to face training.
• The practice had implemented a system for checking that the medical indemnity insurance and professional registration of clinicians was up to date.
• The practice held evidence of Disclosure and Barring Service (DBS) checks for all staff as appropriate.
• The practice had implemented a programme of appraisals and supervision for all staff. Personal development plans had been put in place.
• The practice had updated the way they dealt with complaints. We saw that all complaints were documented and investigated, with appropriate responses being issued. Complaints were discussed in meetings and learning actions were monitored.
• The patient participation group (PPG) had started to have regular meetings. Feedback from the PPG regarding their involvement with the practice and them being able to make suggestions was positive.
• The practice had an open surgery each morning and all patients attending before 10am were seen. Children were also seen on the day when required.

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

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

On 12 February 2019 we carried out a full comprehensive inspection at Littletown Family Medical Practice, 53 Manchester Road, Oldham, OL8 4LR. The practice was given an overall rating of inadequate and placed into special measures. The domain ratings were as follows:

Safe – inadequate

Effective – requires improvement

Caring – good

Responsive – requires improvement

Well-led – inadequate

Requirement notices were issued in respect of Regulation 10 HSCA (RA) Regulations 2014 (Dignity and respect) and Regulation 16 HSCA (RA) Regulations 2014 (Receiving and acting on complaints).

On 26 March 2019 a warning notice was issued in respect of Regulation 17 HSCA (RA) Regulations 2014 (Good governance).

On 3 July 2019 we carried out a focussed inspection to check that the practice had complied with the requirements of the March 2019 warning notice.

We found that although the practice had started to put new systems and processes in place these were not yet fully developed and further improvement was necessary.

In particular we found:

• A fire risk assessment and infection control audit had been carried out. However, actions required following these had not been put in place.
• Sharps bins were hung on walls in a manner that was not secure and they were left open, so posed an infection control risk.
• The procedure for dealing with significant events and complaints had been reviewed but was not yet fully embedded.
• The practice was in the process of creating a procedure to record and monitor staff training, professional registration and medical indemnity insurance. This was not yet complete.
• Not all staff had had an appraisal and the process for monitoring these was not yet in place.
• The practice had re-launched their patient participation group (PPG) and two meetings had been held.
• Fire training and fire warden training had been carried out. However, not all staff had been trained in infection prevention and control.
• A process for correctly monitoring the temperatures of fridges containing vaccines had been put in place. We saw that these checks were performed accurately and were up to date.

The rating of inadequate awarded to the practice following our full comprehensive inspection on 12 February 2019 remains unchanged and the practice remains in special measures. A further full inspection of the service will take place within six months of the original report being published (23 April 2019) and their rating revised if appropriate. 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.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Littletown Family Medical Practice on 12 February 2019 as part of our inspection programme. We previously inspected the practice 17 March 2015 and the practice was then rated as good in all domains.

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 have rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice had only recently carried out its first infection control audit and did not have a plan in place to make the improvements required. Not all staff had received infection control training.
• A general fire risk assessment had been carried out in February 2010 and had not been updated. There was only one trained fire warden.
• Staff had incorrect information about checking medicine fridge temperatures, so actions had not been taken when the temperature was outside the safe range.
• Some sharps bins were not wall-mounted and had been opened since May 2017.
• Significant events were not adequately managed so learning was not identified or disseminated.
• The practice did not have sight of completed Disclosure and Barring Service (DBS) checks for all clinicians.
• The practice did not check that medical indemnity insurance was in place for all clinicians.
• The practice did not have a system to check the ongoing professional registration status of clinicians.

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

• The practice was unable to show that all staff had the skills, knowledge and experience to carry out their roles.
• The practice did not provide a formal induction for new staff.
• Staff did not receive ongoing supervision or regular appraisals of their performance so training and development needs were not identified.

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

• There was a lack of privacy in some clinical consultation rooms. Conversations could be overheard, and one door had an unobscured window.
• The practice had identified a low number of patients who were carers (0.1%) so appropriate support could not be offered.

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

• The system for managing complaints was not effective. Not all complaints were investigated or responded to, and where complainants did receive a response they were not provided with all the appropriate information. We saw no evidence of learning from complaints.

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

• The arrangements for governance did not always operate effectively. For example, we saw examples of generic policies not being personalised to the practice, and policies that had been reviewed but were not being followed.
• We saw examples of ineffective performance management. The practice manager had never had an appraisal and appraisals for other staff were irregular. Some tasks that had been delegated were not being performed.
• There was a limited approach to obtaining the views of patients. The patient participation group was not active and a patient survey carried out in early 2017 had not been repeated.
• Although the majority of recruitment checks were being carried out there was no system to monitor ongoing checks.
• Risks, issues and poor performance had not been identified and so had not been dealt with.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

• Ensure the privacy of the service user.
• Ensure there is an accessible system for identifying, receiving, recording, handling and responding to complaints.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Take action to increase the number of patients who are carers.
• Formalise the programme of clinical audits so they are well-recorded and reviewed.
• Relaunch the patient participation group so patient’s view can be collected.
• Ensure sharps bins are secure and sealed within the appropriate time.

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.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care