The Care Quality Commission
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  • GP practice

Archived: Chiltern House Medical Centre

Overall: Good read more about inspection ratings

45-47 Temple End, High Wycombe, Buckinghamshire, HP13 5DN (01494) 439149

Provided and run by:
Chiltern House Medical Centre

All Inspections

10 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Chiltern House Medical Centre in High Wycombe, Buckinghamshire on 18 and 24 October 2016. The overall rating for the practice was inadequate. We used our enforcement powers to take action against the breaches of regulations including issuing three warning notices. We placed the practice in special measures to enable the practice to improve. The significant levels of concern led to three conditions being added to the registration of the practice. The conditions were imposed to ensure timely and sustainable improvement was made.

We undertook a second comprehensive inspection on 6 June 2017. This inspection was undertaken to determine whether the breaches of regulation requirements had been addressed following the inspection in October 2016. Whilst improvements had been made in relation to some of the concerns highlighted at the last inspection, there were areas relating to providing safe, effective, caring and well-led services which constituted continued breaches of regulations. The overall rating of the practice remained as inadequate, specifically inadequate for the provision of safe, effective, caring and well-led services. The practice was rated good for providing responsive services. The issues identified at the inspection impacted the care provided to all population groups which were also rated as inadequate.

We carried out an announced comprehensive inspection on 10 January 2017. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Chiltern House Medical Centre meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection in January 2018 we found that significant improvements had been taken to improve the provision of care and treatment. Overall the practice is now rated as good.

Following the January 2018 inspection, the key questions are rated as:

  • Are services safe? – Good
  • Are services effective? – Good
  • Are services caring? – Good
  • Are services responsive? – Good
  • Are services well-led? - Good

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 – Good
  • People with long-term conditions – Good
  • Families, children and young people – Good
  • Working age people (including those recently retired and students – Good
  • People whose circumstances may make them vulnerable – Good
  • People experiencing poor mental health (including people with dementia) - Good

Our key findings at this inspection were as follows:

  • It was evident the practice had gone through a period of transition including the implementation of a new management team. Positive changes had been made to the leadership team. The managing GP partner had a more active role in the management and leadership of the practice. Staff we spoke with recognised the endeavours of the new leadership team and were keen to be part of the new developments.
  • The practice now had a clear vision that had improvement of service quality and safety as its top priority. The practice fully embraced the need to change, high standards were promoted and there was good evidence of team working.
  • Significant improvements to risk management had been made and risks to patients were now being assessed and managed. This included concerns from the previous inspections.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. For example, there was a comprehensive sepsis decision support tool. Sepsis is a rare but serious complication of an infection. Without quick treatment, sepsis can lead to multiple organ failure and death. We saw there was a proactive approach to anticipate and manage the risk of sepsis.
  • Improved systems now ensured patients received timely reviews where treatment or interventions may be required. This included a review of pathology results (pathology is the medical speciality relating to the diagnosis of disease based on the laboratory analysis of bodily fluids such as blood and urine), a review of patients on more than four repeat medicines and annual health checks for patients with learning disabilities.
  • Data showed most patient outcomes were similar when compared to local and national averages. The practice reviewed and monitored patient outcomes through the use of a clinical effectiveness plan which planned appropriate actions to identify and improve patient’s health and well-being.
  • Revised systems to seek, act and monitor feedback. The practice had undertaken various actions to identify and act on patients' concerns reflected in the July 2016 national GP survey and more recently the July 2017 national GP survey. Feedback from patients relating to access to services and the quality of care had improved. This was corroborated by written and verbal feedback collected during the inspection.

The areas where the provider should make improvements are:

  • Continue to improve patient recall and reviews for patients with a learning disability. Specifically, increase uptake for patients with a learning disability attending or having a completed health check.
  • Continue to seek feedback and improve engagement with patients whilst reviewing the outcomes of patient feedback including patient surveys to determine appropriate action with a view to improving the patient experience.
  • The leadership team should continue to review and sustain the improvements made to the overall governance and management of the practice.

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

7 September 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of Chiltern House Medical Centre in High Wycombe, Buckinghamshire on 7 September 2017. This was to follow up on the two warning notices we (Care Quality Commission) served following an announced comprehensive inspection on 6 June 2017.

Following the June 2017 inspection, the practice was rated inadequate overall, specifically inadequate for the provision of safe, effective, caring and well-led services. The practice was rated good for the provision of responsive services. In addition to the overall rating, all six population groups were rated as inadequate.

The warning notices we served related to Regulation 12 Safe care and treatment and Regulation 17 Good governance of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notices was 16 August 2017. The practice provided regular improvement updates to Care Quality Commission alongside a submitted action plan detailing the actions they were taking to meet legal requirements.

This report covers our findings in relation to those requirements. Due to the focussed nature of this inspection the ratings for the practice have not been updated. We will conduct a further comprehensive inspection within six months of publication of the report of the inspection undertaken in June 2017.

The comprehensive report from the June 2017 inspection can be found by selecting the ‘all reports’ link for Chiltern House Medical Centre on our website at www.cqc.org.uk and should be read in conjunction with this report.

At this inspection in September 2017 we found that actions had been taken to improve the provision of safe and well led services. Specifically the practice had:

  • Improved systems which now ensured patients received timely reviews where treatment or interventions may be required. This included a review of pathology results (pathology is the medical speciality relating to the diagnosis of disease based on the laboratory analysis of bodily fluids such as blood and urine), a review of patients on more than four repeat medicines and annual health checks for patients with learning disabilities.

  • Improved the management of medicines, specifically medicine and other safety alerts including alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).

  • Strengthened safeguarding arrangements to keep patients safe from harm.

  • Continued to make improvements in how the practice managed infection prevention control. This included a review of the existing arrangements for the collection of specimens and samples from patients which now reflected national guidance.

  • Implemented a wide range of actions which had resulted in improvements to the existing governance arrangements with a view to keep patients safe.

  • Reviewed governance arrangements for recruitment and personnel records within the practice. The practice had addressed concerns regarding gaps in recruitment correspondence.

  • Revised systems to seek, act and monitor feedback. The practice had undertaken various actions to identify and act on patients' concerns reflected in the July 2016 national GP survey and more recently the July 2017 national GP survey. To further review patient satisfaction, the practice had completed an in-house survey with an additional survey planned for December 2017.

  • Undertaken further clinical audits and demonstrated improvements to patient care and outcomes.

  • Positive changes had been made to the leadership team. The managing GP Partner had a more active role in the management and leadership of the practice. Staff we spoke with recognised the endeavours of the new leadership team and were keen to be part of the new developments.

The practice was originally placed into special measures in December 2016. We found insufficient improvements had been made at the June 2017 inspection. As a result, the practice was kept in special measures and the conditions of registration remain due to the continued concerns we identified in June 2017.

At this inspection we found that the practice had taken action to address the breaches of regulation set out in the warning notices issued following the June 2017 inspection. However, the practice will remain in special measures until they receive a further comprehensive inspection.

Keeping the practice in special measures will give people who use the service the reassurance that the care they get should improve. Chiltern House Medical Centre will be kept under close review and inspected again within six months. If we do not see satisfactory improvement we will escalate our enforcement powers, which may result in the closure of the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

6 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Chiltern House Medical Centre in High Wycombe, Buckinghamshire on 18 and 24 October 2016. The overall rating for the practice was inadequate with one rating of requires improvement for providing effective services; all other areas were rated inadequate. We used our enforcement powers to take action against the breaches of regulations including issuing three warning notices. We placed the practice in special measures for six months to enable the practice to improve. The significant levels of concern led to three conditions being added to the registration of the practice. The conditions were imposed to ensure timely and sustainable improvement was made. We undertook a focussed follow up inspection in January 2017 and found the warning notices had been met. However, the practice remained in special measures and the conditions of registration remained in place. The full comprehensive report from these inspections can be found by selecting the ‘all reports’ link for Chiltern House Medical Centre on our website at www.cqc.org.uk.

We undertook a comprehensive follow up inspection on 6 June 2017. This inspection was undertaken to determine whether all of the breaches of regulation requirements had been addressed following the inspection in October 2016. Whilst improvements had been made in relation to some of the concerns highlighted at the last inspection, there were areas relating to providing safe, effective, caring and well-led services which constituted continued breaches of regulations. The practice is rated inadequate overall, specifically inadequate for the provision of safe, effective, caring and well-led services. The practice was rated good for providing responsive services. The issues identified at this inspection impact on the care provided to all population groups which have also been rated as inadequate.

Our key findings were as follows:

  • The GP partners demonstrated they had the motivation to improve the services patients experienced. However, the overall leadership and management team of the practice did not always ensure the appropriate systems were in place to ensure improvements were followed through.
  • There was not an effective system or culture for identifying, capturing and managing issues and risks. Significant issues that threaten the delivery of safe and effective care were not identified or adequately managed. For example, risks related to staff background checks and infection control were not always identified, assessed and mitigated.
  • Improvements to the monitoring of care and treatment had been implemented and we saw most clinical daily tasks were undertaken efficiently. However, we saw some areas where patients were at risk of delays in receiving follow up care in relation to pathology results and external correspondence.

  • Patients were at risk of harm because systems and processes were not appropriately embedded to keep them safe. For example, repeat prescribing was not always managed properly to ensure reviews of medicines were up to date or that medicine alerts were responded to promptly.

  • The care of long term conditions had improved overall according to national data submission from 2016/17. However, diabetes performance data showed a decline from 2015/16.
  • There was evidence of some monitoring of patients care and treatment, including seven repeated clinical audits. However, clinical audit was related primarily to medicine audits and no broader audit based on patient care outcomes was undertaken or was only in its preliminary stages.
  • Staff were able to access clinical training in order to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, training requirements and qualifications were not always monitored to ensure they were being undertaken by all staff.
  • There had been improvements made in the premises at the branch practice to reduce any risks to patients and enhance accessibility.
  • There had been improvement to telephone access and appointment availability.
  • There was a system in place for reporting and recording significant events. Reviews of complaints, incidents and other learning events were used to identify learning and improve services.
  • Patients said they were treated with compassion, dignity and respect and they 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.
  • Patient feedback in Care Quality Commission (CQC) comment cards showed patients felt improvements had been made to the quality of the service in recent weeks.
  • The provider was aware of and complied with the requirements of the duty of candour.

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

Importantly, the provider must:

  • Review the leadership and management visibility, capability, capacity and experience in order to ensure the practice effectively makes sustainable and measurable improvements to the governance processes. Including clinical audit in relation to areas where clinical data shows improvement is required and responding to feedback from stakeholders as well as all patient feedback.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure risks related to the provision of regulated activities are identified, assessed and managed. Specifically review risks related to staff background checks and infection control.
  • Ensure care and treatment is provided in a safe way to patients including the prescribing of medicines and care provisions for patents with learning disabilities.
  • Ensure persons employed in the provision of the regulated activities receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties
  • Ensure, where appropriate, persons employed with the relevant qualifications.
  • Provide staff with appropriate supervision and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

This practice was placed in special measures in December 2016. Insufficient improvements have been made such that the practice is now rated inadequate for several key questions (safe, effective, caring and well-led). As a result, I am keeping the practice in special measures and the conditions of registration remain due to the continued concerns we identified in June 2017.

One of the conditions of registration that remain specifically prevents the practice registering any new patients without the written permission of the CQC unless those patients are the newly born babies, newly fostered or adopted children of patients already registered at Chiltern House Medical Centre or Dragon Cottage Surgery.

Chiltern House Medical Centre will be kept under close review and inspected again within six months. If we do not see satisfactory improvement we will escalate our enforcement powers, which may result in the closure of the service.

We have shared the seriousness of our concerns and potential action regarding Chiltern House Medical Centre with NHS England and the Chiltern Clinical Commissioning Group.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

31 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Chiltern House Medical Centre on 18 and 24 October 2016. The overall rating for the practice at that time was inadequate and the practice was placed into special measures. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Chiltern House Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 31 January 2017 to follow up on warning notices the Care Quality Commission served following the unannounced

comprehensive inspection in October 2016. The warning notices were served relating to regulation 12 Safe care and treatment, regulation 15 Premises and equipment and regulation 18 Staffing respectively of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notices was 30 December 2016. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. This report covers our findings in relation to those requirements. Due to the focussed nature of this inspection the ratings for the practice have not been updated. We will conduct a further comprehensive inspection within six months of publication of the report of the inspection undertaken in October 2016.

Our key findings were as follows:

  • Monitoring processes to ensure appropriate standards of cleanliness had been implemented.The standards of cleanliness throughout the practice had improved.
  • The processes to enable nurses to administer medicines met legal requirements.
  • A relevant assessment of access for people with a disability had been undertaken and improvement actions had been taken or planned arising from the assessment.
  • There were sufficient nurses on duty to provide a safe and accessible service to patients.
  • Management systems to ensure the safety of medicines requiring refrigeration were appropriate.
  • The practice held stocks of controlled drugs (medicines that require extra checks and special storage because of their potential misuse). The procedures in place to manage these drugs safely did not always follow national guidance.
  • The practice held appropriate stocks of medicines to deal with emergencies but the system to check these were fit for use was operated inconsistently.

There were also areas of practice where the provider continued to need to make improvements.

Importantly, the provider must:

  • Ensure controlled drugs are managed and stored in accordance with regulations.
  • Ensure systems to monitor expiry dates of emergency medicines are managed consistently.

At our previous inspection on 18 and 24 October 2016, we rated the practice as inadequate overall and the practice was placed into special measures. At this inspection we found that the practice had taken action to address most of the breaches of regulation set out in the warning notices issued in November 2016. However, the practice will remain in special measures until they receive a further inspection to assess the improvements achieved against all breaches of regulation identified in October 2016. If there is not enough improvement we will move to close the service.

Keeping the practice in special measures will give people who use the service the reassurance that the care they get should improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 and 24 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Chiltern House Medical Centre on the 18 October 2016. This was to follow up on concerns identified at an inspection in February 2016, when the practice was rated Requires Improvement overall and in the safe, effective, caring, responsive and well-led domains. Due to the levels of concern identified at Chiltern House Medical Centre on the 18 October 2016 and poor feedback received about the branch practice, we also made an announced visit to Dragon Cottage Surgery on the 24 October 2016. Overall the practice is rated as inadequate.

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

  • The practice has been through significant changes since 2014. Two practice managers joined and left the practice between April 2015 and October 2015. Two further practice managers were recruited and from January 2016 have commenced with the implementation of concern and risk improvements set out by NHS England in February 2015.

  • The practice had a leadership structure, but there was insufficient leadership capacity and governance arrangements to support the delivery of high quality care and services for patients. Weak leadership and management capacity has led to only a partial completion of the NHS England action plan, which was developed with the practice in early 2016. There were continued breaches in regulation for the areas of concerns identified at the last CQC inspection in February 2016.

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, fridge temperature recording was inconsistent and the practice had not followed their own policy when records highlighted a risk; legal documentation to support the safe delivery of immunisations and vaccinations were out of date; medicines checks had not identified out of date items at the Dragon Cottage Surgery; risk assessments with concerns identified and poor access feedback from patients had not been fully addressed. The cleanliness of treatment and consultations rooms at Chiltern House Medical Centre was also poor.

  • Very few clinical audits or quality improvement measures had been undertaken since the last inspection. A recent meeting outlined how the practice was to reinstigate a clinical governance framework and policy, but this was in development and it was too early to assess the effectiveness.

  • Staff were clear about reporting incidents, near misses and concerns but the learning and actions were not always communicated to staff.

  • Patient’s feedback through the national GP survey showed worsening results when compared to the previous survey in December 2015. The results were often lower than CCG and national averages. The practice had not identified the poor patient feedback advertised on the Healthwatch Buckinghamshire website or NHS Choices. Minimal action had been taken to make improvements from the patient feedback.

  • Appointment systems were not working well so patients did not receive timely care when they needed it.

The areas where the provider must make improvements are:

  • Ensure the premises used by patients are safe, clean, secure, suitable for the purpose they are used and properly maintained.

  • Review the leadership and management capability, capacity and experience in order to ensure the practice effectively makes sustainable and measurable improvements to the governance processes. Including the management of significant events, infection control, medicines management, clinical audit and quality improvement, the management of risk and have appropriate up to date documentation and policies in place. Ensure patient feedback is reviewed and acted upon to improve the services for patients.

  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed to meet the requirements of the regulations and also to maintain and sufficient, accessible and safe level of service to patients.

  • Implement and make improvements to ensure all care and treatment is undertaken in a safe way. For example, the safe management of medicines.

The areas where the provider should make improvement are:

  • Review and improve the processes to identify carers in the practice population to ensure they are offered the correct support, care and treatment.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chiltern House Medical Centre on 25 February 2015. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, only three incidents had been documented in the preceding 12 months and learning was not shared to improve patient outcomes.

  • Risks to patients were being reviewed and assessed as part of an improvement plan between the practice and NHS England. Those already identified and implemented were well managed. There were known gaps in staff recruitment files and mandatory training which were being updated through a rolling staff programme by the practice manager.

  • Data showed patient outcomes were low compared to the locality and nationally.

  • We saw evidence that audits had been undertaken, although an established programme of audit was not in place.

  • Patients said they were treated with compassion, dignity and respect, although access to appointments was less positive. Urgent appointments were usually available on the day they were requested.

  • Information about services and how to complain was available and easy to understand.

  • The practice had a number of policies and procedures to govern activity. Many had been reviewed and some were still being embedded in practice.

  • The practice had sought feedback from patients and was working with the local healthwatch to form a patient participation group.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. A lift was available to allow access to consultation rooms on the first floor.

  • There was a clear leadership structure and staff felt supported by management.

We saw one area of outstanding practice:

One of the GPs had initiated a diabetes Ramadan project working with the local Imam (Muslim faith leader) to support patients of Muslim faith during the fasting period. The project was self-funded for the first year and the GP had received funding from the CCG for the project last year. Lessons learned from both these projects have been shared locally and nationally to improve patient outcomes.

The areas where the provider must make improvements are:

  • Ensure governance systems and processes are reviewed and improvements continue to be implemented.

  • Ensure all mandatory training is implemented for all staff to the correct level and updates are offered accordingly. All appraisals to be completed within the timescales set by NHS England.

  • Ensure all equipment checks and safety risk assessments are completed and remain on a rolling rota. Consider the arrangements for using the emergency grab bag for home visits and ensure safety in an emergency is maintained within the practice.

  • Ensure recruitment arrangements include all necessary employment checks for all staff within the timescale set by NHS England, including DBS checks, performers list and Hepatitis B status for all clinical staff.

  • Ensure that all significant events are identified and reported in a timely way. Document and investigate safety incidents thoroughly and share learning with staff. In addition, ensure that patients affected by significant events receive reasonable support and a verbal and written apology.

  • Ensure learning from complaints is shared and communicated to all staff.

  • Complete and implement the audit strategy as outlined by NHS England.

  • Implement a patient participation group and ensure feedback from patients is monitored and responded to.

  • Implement a rota of staff meetings, including Clinical governance and whole team meetings and ensure documentation of these meetings is stored appropriately and available for review.

  • Implement flexible and timely arrangements for providing the childhood immunisation programme and ensure there is adequate cover at all times.

  • Improve the availability of non-urgent appointments and appointments with the GP of choice.

  • Ensure all the regulatory breaches as outlined in the requirement notices are comprehensively implemented into the NHS England improvement plan.

  • Ensure an infection control lead is appointed, cleaning is regularly monitored and cleaning schedules are adhered to.

  • Ensure recruitment checks for GP performers list are clearly documented and retained.

  • Ensure policies reflect up to date legislation and guidance.

The areas where the provider should make improvements are:

  • Ensure care plans are reviewed and updated to reflect any changes in patient circumstances.

  • Monitor and improve patient outcomes for diabetes.

  • Review and update the carers register to ensure all carers are offered support.

  • Continue to review and update procedures and guidance according to deadlines set by NHS England.

  •  Continue to review patient feedback and make improvements to accessing the practice and appointment booking.

    Professor Steve Field (CBE FRCP FFPH FRCGP) 

    Chief Inspector of General Practice