Pelham Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pelham Medical Practice on 30 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Pelham Medical Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection on 4 January 2017 to see whether the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified on 30 March 2016. Although the practice had made some improvements these were not sufficient. Therefore we found a breach of legal requirements

and the practice was rated requires improvement overall. The practice was rated inadequate for providing well-led services, requires improvement for safe and effective services and good for providing caring and responsive services.

Following this inspection we issued a warning notice in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17, Good Governance, which stated that the practice must comply with the legal requirements in relation to the following:

• Ensure that safety alerts including those from the Medicines and Healthcare Products Regulatory Agency (MHRA) in relation to monitoring and managing safety in primary medical services were received and made available to relevant staff.
• Ensure embedded systems to prevent, detect and control the spread of infections, to patients and staff.
• Ensure the proper and safe management of medicines and their disposal when of out of date.
• Implement a system to ensure that staff members were trained, including safeguarding training at the appropriate level.
• Ensure a system and process for the timely sharing of patient information particularly in relation to a backlog of scanning at the practice.

This inspection was an announced focused inspection carried out on 3 May 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations identified in the warning notice issued following our previous inspection on 4 January 2017. This report covers our findings only in relation to the requirements of the warning notice and will not result in reviewing the overall rating or the ratings of any individual key question or population group.

Our key findings at this inspection, 3 May 2017, were as follows:

• The practice had devised a new system to manage national patient safety alerts. They were able to demonstrate that alerts were being discussed at clinical meetings and that action was being taken in relation to receipt of alerts.

• Infection control audits had been carried out and there was evidence of action being taken where issues were highlighted.
• Medicines were managed safely and the expiry dates were subject to on-going audit.
• The practice were able to demonstrate that there was a system for identifying and implementing staff training. The practice were working with the Clinical Commissioning Group (CCG) to identify role and person specific training requirements. Safeguarding training had been carried out at the appropriate level.
• A new scanning protocol had been introduced. The practice was able to demonstrate that the process for receiving patient information and scanning this onto the patient record was carried out in a timely way.

We carried out an announced comprehensive inspection at Pelham Medical Practice on 12 September 2017. Overall the practice is now rated as good.

Our key findings across all the areas we inspected 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 clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of 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 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their 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 that there was continuity of care, with urgent appointments 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.

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

The provider should:

• Continue to work to improve patient satisfaction, as reflected in the GP patient survey results.

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 Pelham Medical Practice on 30 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Pelham Medical Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection on 4 January 2017 to see whether the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified on 30 March 2016. Although the practice had made some improvements these were not sufficient. Therefore we found a breach of legal requirements

and the practice was rated requires improvement overall. The practice was rated inadequate for providing well-led services, requires improvement for safe and effective services and good for providing caring and responsive services.

Following this inspection we issued a warning notice in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17, Good Governance, which stated that the practice must comply with the legal requirements in relation to the following:

• Ensure that safety alerts including those from the Medicines and Healthcare Products Regulatory Agency (MHRA) in relation to monitoring and managing safety in primary medical services were received and made available to relevant staff.

• Ensure embedded systems to prevent, detect and control the spread of infections, to patients and staff.

• Ensure the proper and safe management of medicines and their disposal when of out of date.

• Implement a system to ensure that staff members were trained, including safeguarding training at the appropriate level.

• Ensure a system and process for the timely sharing of patient information particularly in relation to a backlog of scanning at the practice.

This inspection was an announced focused inspection carried out on 3 May 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations identified in the warning notice issued following our previous inspection on 4 January 2017. This report covers our findings only in relation to the requirements of the warning notice and will not result in reviewing the overall rating or the ratings of any individual key question or population group.

Our key findings at this inspection, 3 May 2017, were as follows:

• The practice had devised a new system to manage national patient safety alerts. They were able to demonstrate that alerts were being discussed at clinical meetings and that action was being taken in relation to receipt of alerts.

• Infection control audits had been carried out and there was evidence of action being taken where issues were highlighted.

• Medicines were managed safely and the expiry dates were subject to on-going audit.

• The practice were able to demonstrate that there was a system for identifying and implementing staff training. The practice were working with the Clinical Commissioning Group (CCG) to identify role and person specific training requirements. Safeguarding training had been carried out at the appropriate level.

• A new scanning protocol had been introduced. The practice was able to demonstrate that the process for receiving patient information and scanning this onto the patient record was carried out in a timely way.

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 Pelham Medical Practice on 30 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Pelham Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 4 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 30 March 2016.

This report covers our findings in relation to those requirements which we found were not sufficiently met as significant action had not been taken by the practice to make improvements since our last inspection. Additionally, a breach of the legal requirements was

found because systems and processes had not been established and operated effectively. As a result, the provider was not assessing, monitoring and improving the quality and safety of the services provided and mitigating the risks related to the health, safety and welfare of service users and others. Therefore, a Warning Notice was served in relation to Health and Social Care

Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance.

Overall the practice is still rated as requires improvement.

Our key findings were as follows:

• The practice had devised a new system to manage national patient safety alerts, however, they were unable to demonstrate that alerts were being discussed at clinical meetings or that action was being taken in relation to receipt of alerts. Documents provided after the inspection demonstrated that alerts were discussed and that action was taken in relation to these.

• Infection control audits had been carried out but there was no evidence of action being taken where issues were highlighted. Documents provided after the inspection demonstrated that action had been taken.

• Medicines were not always managed safely.

• The practice were unable to demonstrate that all staff were up to date with training. For example, safeguarding, infection control and basic life support. Documents provided after the inspection demonstrated that the practice were working with the clinical commissioning group (CCG) to identify role and person specific training requirements and to implement this for all staff.

• The practice had revised the staff appraisal system and records showed that the practice had introduced a process where GP partners carried out nurses’ appraisals instead of non-clinical staff.

• Data from the GP patient survey was deemed comparable to other practices.

• The practice was not an outlier for the aspects of QOF identified at the comprehensive inspection on 30 March 2016, and some improvements had been made to address clinical targets.

• A new scanning protocol had been introduced; however, the practice was unable to demonstrate that the process for receiving patient information and scanning this onto the patient record was carried out in a timely way. Documents provided after the inspection showed that all scanning was up to date and that a timeframe had been added to the scanning protocol so that all information was scanned onto the system within 48 hours.

• There had been two clinical audits undertaken since our previous inspection in March 2016 and these were completed audits where the improvements made were implemented and monitored.

• A confidentiality marker line and flag had been established at a distance from the reception desk to separate the patient speaking at reception from the queue.

• The practice had revised their governance structure and had made some improvements.

• The practice had employed a new practice manager who was able to provide documents to demonstrate the implementation of a structure to support delivery.

• The practice had revised and updated their duty of candour statement.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• At our previous inspection on 30 March 2016, we told the practice that they must ensure that training is in place for all staff. At this inspection we found that training for staff had still not improved. The provider must ensure that training appropriate to job role is completed by all clinical and non-clinical staff and GPs, including safeguarding children and vulnerable adults.

• Ensure that policies and procedures provide suitable guidance to staff with regards to the storage of medicine and the disposal of out of date medicine and blood bottles.

• At our previous inspection on 30 March 2016, we told the practice that they must take action to address identified concerns with infection prevention and control practice. At this inspection we found that the action had not been sufficiently taken. The provider must take action to address identified concerns with infection prevention and control.

• At our previous inspection on 30 March 2016, we told the practice that they must ensure that protocols for the scanning of clinical correspondence are adhered to. At this inspection we found that the process for scanning patient information had still not improved. The provider must ensure that a timely system is introduced for scanning information onto patient records and their IT system.

The areas where the provider should make improvement are:

• Continue to embed the process to share information regarding safety alerts and take action as required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice