Coltishall Medical Practice

We carried out an announced focused inspection of Coltishall Medical Practice between 22 and 25 September 2020. This inspection was carried out in response to concerns raised in relation to the management of medicines. The inspection focused on specific areas of the following key questions:

• Are services safe?
• Are services effective?
• Are services well-led?

This inspection was completed as part of the Care Quality Commission’s GP Focused Inspection Pilot in response to the Covid-19 pandemic. This meant that more information was obtained from the provider prior to the inspection site visit, including searches of the clinical system which were remotely installed on the practice system by CQC on 17 September 2020. The information from these searches was analysed during the inspection site visit.

The key questions are rated as:

• Are services safe? – Inadequate
• Are services effective? – Inadequate
• Are services well-led? – Inadequate

This was a focused inspection responding to specific areas of concern. Therefore not all areas within safe were reviewed or reported upon. At this inspection, the practice was rated as inadequate for providing safe services because:

• We found the practice’s system for managing patient and drug safety alerts did not ensure medicines were prescribed safely. We found the practice had not actioned any of the three alerts we reviewed, which affected up to 51 patients. There was no evidence to show the practice had taken action to protect all of those patients from avoidable harm.
• The practice did not evidence a safe system to ensure patients on high risk medicines were appropriately managed in a timely way. We reviewed nine high risk medicines and found seven were not appropriately managed, affecting 177 patients.
• The practice’s safeguarding processes and systems did not ensure patients were kept safe from harm. We found patients with safeguarding concerns did not have appropriate indicators or alerts on their records. This meant that other clinicians and services, such as out of hours services reviewing the patient records, would not be alerted to the concerns. The practice’s child safeguarding policy was incomplete and we found not all staff were trained appropriately to their role.
• The practice did not fully evidence that patients had a structured and comprehensive medicine review. We identified reviews had been coded on the clinical system but there was no evidence in the clinical records of a structured medicine review or consultation with the patient. We reviewed patient consultation records and found discrepancies with the coding of medical records.
• The practice did not provide evidence they had oversight of all staff vaccinations in line with current Public Health England guidance.
• We identified concerns in relation to the practice’s basic life support training and emergency procedures and training.
• We reviewed the practice’s system for managing pathology results and found that there was not a robust system to ensure urgent abnormal results were always reviewed and acted on in a timely way.
• The practice had higher levels of broad spectrum antibiotic prescribing compared with CCG and England averages. The practice had completed an audit, but no actions had been taken at the time of the inspection to try and improve the prescribing rate and improve patient outcomes.
• We found the practice did not have oversight of the progress of actions arising from an infection prevention and control audit carried out in February 2020. We found the practice had not taken action despite the current Covid-19 pandemic at the time of the inspection.
• The process for recording, investigating and learning from significant events did not ensure safe care and treatment. We found the practice had not identified themes or learnt from previous events as similar errors were repeated, leading to significant patient safety concerns.

This was a focused inspection responding to specific areas of concern. Therefore not all areas within effective were reviewed or reported upon. At this inspection, the practice was rated as inadequate for providing effective services because:

• The practice failed to evidence patients’ needs were adequately assessed. We found care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance
• We found a number of examples where clinical coding was missing from patient records or the clinical coding applied was not accurate. The poor quality coding of patient records meant that patient’s needs were not always identified and therefore they were not always given appropriate care and treatment.
• Due to the failings of the practice to ensure clear and accurate record keeping we were not assured care was effective for patients across all population groups.
• The practice failed to have an effective system in place for recalling, monitoring or treating patients with a potential diagnosis of diabetes. This did not ensure these patients received proactive care and advice to make informed choices and life style changes to prevent further deterioration of their health.
• The practice’s quality improvement program did not reliably identify or respond to patients needs to ensure they received appropriate or proactive care in line with guidance. This was further impacted by inappropriate, incorrect or missing coding.

This was a focused inspection responding to specific areas of concern. Therefore not all areas within well-led were reviewed or reported upon. At this inspection, the practice was rated as inadequate for providing well-led services because:

• We found a lack of leadership capacity and capability to successfully manage challenges and implement and sustain improvements. The GP partners failed to provide leadership to ensure effective and cohesive team working.
• We found the GP partners did not work effectively as a partnership team and we were told of disharmony amongst the partnership at the time of the inspection.
• The practice could not evidence that risks, issues and performance were managed to ensure that services were safe or that the quality of those services was effectively managed. We found examples where patient care was of poor quality and the practice had failed to act.
• We found a lack of governance and assurance structures and systems which led to significant patient safety concerns identified at this inspection.
• We found and the practice told us that internal and external meetings had not occurred during the Covid-19 pandemic. This led to patient and staff being put at risk of harm as they were not aware of relevant updates and guidance, such as to basic life support training or infection control.
• The practice did not evidence that learning was shared effectively and used to make improvements. We found learning from previous events was not taken forward and similar errors were repeated leading to significant patient safety concerns.

The areas where the provider must make improvements are:

• 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.

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.

Special measures will give people who use the service the reassurance that the care they get should improve.

As a result of the findings from our focused inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue an urgent notice of decision to impose conditions on the provider’s CQC registration. For further information see the enforcement section of this report.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care