Background to this inspection
Updated
11 June 2018
The Woodrow Medical Centre was a GP practice which provided primary medical services under a General Medical Services (GMS) contract to a population of approximately 3,900 patients living in the Woodrow and surrounding areas of Redditch, Worcestershire. A GMS contract is a nationally agreed contract used for medical services providers. The practice had a branch practice at Millstream Surgery, Cherry Tree Walk, Redditch. We did not inspect this branch as the practice had closed it at the time of our inspection due to being short staffed.
The practice operated from a single storey building which had parking facilities on site and an easily accessible car park opposite the premises. There was a disabled access approach to the main reception with a bell system to alert staff to provide assistance to open the main door if required. There was a spacious waiting area allowing easy access for patients with mobility aids to manoeuvre.
The practice population had a higher than average number of patients aged 0 to 40 years and a significantly lower than average number of patients in the 60 to 85 year age group. National data indicated that the area was one that experienced high levels of deprivation. The practice population was mixed with high numbers of patients from ethnic groups, whose first language was not English such as Indian and Pakistani. The practice had four partners; three of these were GPs and the fourth partner was a nurse practitioner who worked full time at the practice. One of the GP partners did not carry out clinical work in the practice and was a silent partner. The practice employeda salaried GP and a practice manager who were supported by two administration and reception staff.
The practice was open at the following times:
• Monday: 7am to 6pm
• Tuesday: 8.30am to 6pm
• Wednesday: 8.30am to 5pm
• Thursday: 8.30am to 6pm
• Friday: 8.30am to 6pm
The practice did not provide out of hours services beyond these hours. Patients were provided with information about the local out of hours services provided by Care UK which they could access by using the NHS 111 telephone number.
Updated
11 June 2018
This practice is rated as Inadequate overall. (Previous inspection September 2017 – Good)
The key questions are rated as:
Are services safe? – Inadequate
Are services effective? – Inadequate
Are services caring? – Inadequate
Are services responsive? – Inadequate
Are services well-led? - Inadequate
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 – Inadequate
People with long-term conditions – Inadequate
Families, children and young people – Inadequate
Working age people (including those recently retired and students – Inadequate
People whose circumstances may make them vulnerable – Inadequate
People experiencing poor mental health (including people with dementia) - Inadequate
We carried out an unannounced comprehensive inspection at The Woodrow Medical Centre on 14 March 2018 due to patient safety concerns raised by a whistleblower. The practice had previously been inspected in 2014, 2016 and 2017. We found serious concerns about patient safety and therefore we went back to complete the inspection on 15 March 2018. We asked the practice to submit an action plan on 19 March 2018 to ensure that the serious concerns which put patients at risk had been addressed. We went back to inspect on 19 March 2018 and found that the actions the practice stated they had completed had not been actioned putting patients at extreme risk.
At this inspection we found:
- There were multiple outstanding tasks dating back over several months on the practice computer system. This meant that numerous patients had not been informed of new diagnoses and had not had appropriate or adequate monitoring of their long term conditions such as diabetes, anaemia and high blood pressure.
- There were numerous letters found in one of the GPs’ intray dating back to October 2017 with overdue actions that put patients at risk.
- Work labelled as completed was found to be incomplete again placing patients at risk.
- The practice was found to be approximately three months behind with scanning. This posed a serious risk to patients in that if they had a GP appointment, the GP might not have access to the latest information about their care and treatment.
- There were 70 patient records waiting to be summarised which were stored in a cupboard. The backlog of summarising meant that clinical information about patients was not being transferred to the patients’ electronic records in a timely manner; therefore important information might not be available to clinical staff. There is a serious risk to patients if the notes summary misses key information about a patient.
- We found several examples where monitoring blood tests had not been completed in accordance with national guidelines.
- We found a large number of uncollected prescriptions dating as far back as April 2017. These patients had not been reviewed to see why the prescriptions were not collected. In some cases several months supply of a medicine for the same patient remained uncollected.
- There was a significant risk to patients because there was insufficient clinical capacity to ensure patients received safe care and treatment.
- At the time of our inspection there was one receptionist and one secretary which meant that administration tasks were not getting done. The practice manager had also resigned. We were informed that 11 members of staff had left in the last nine months.
- The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. We found that significant events were not always reported and acted upon. There was no evidence of learning from incidents or and communication of outcomes with staff.
- Patients were at risk of harm because there was a lack of monitoring of the care and treatment of patients. There was a failure of the GPs to treat patients in accordance with national clinical guidelines.
- Children were not protected as there was not an effective system in place to highlight or identify safeguarding concerns.
- The practice provided two urgent appointments per day which was not sufficient as patients were getting turned away.
- There was no focus on continuous learning and improvement.
- Theprovider wasnot managing safety alerts appropriately.
- The practice had not carried out any audits in the last 12 months in order to improve outcomes for patients.
- We found that care and treatment for patients with multiple long-term conditions was below standard. We saw numerous examples of misdiagnoses and inappropriate coding so that patients were not being treated for conditions such as diabetes.
- The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
The provider is no longer providing care or treatment from The Woodrow Medical Centre.
As a result of the inspection team’s findings from the unannounced comprehensive inspection, as to non-compliance, but more seriously, the continuing risk to service users’ life, health and wellbeing, the Commission decided to apply to Redditch Magistrates’ Court to cancel the providers registration to carry out these regulated activities under section 30 of the Health and Social Act 2008.
Section 30 of The Health and Social Care Act 2008 is one of the most severe enforcement powers available to the Commission. Section 30 allows the Commission to make an urgent application to the Magistrates Court seeking urgent cancellation of registration, if, unless the order is made, there will be a serious risk to a person’s life, health or wellbeing. The order for cancellation was granted by the Magistrates Court on Wednesday 21 March 2018 and served upon the provider with immediate effect. The provider, which was a partnership of three GPs and one nurse practitioner, is therefore unable to carry on the regulated activity.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice