Lisson Grove Health Centre

This practice is rated as Good (Previous rating – Good January 2016

The key questions we inspected are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection on 5 June 2019 at Lisson Grove Health Centre to follow up on breaches of regulations.

CQC had previously carried out an announced, unrated, focused inspection on 20 and 21 March 2019 and on 5 April 2019. That focused inspection was triggered by information of concern CQC received. To explore those concerns, our inspection focused on the following three key questions: Are services safe; effective; and well-led? At our last inspection, we also inspected all six population groups under ‘effective’. The published unrated report is available on our CQC website.

At this inspection on 5 June 2019, we inspected all six population groups and rated the Families, Children and Young People population group as inadequate and Working age people population group as requires improvement and the other four population groups as good.

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 Good overall.

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

• Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates in 2017/2018 for the vaccines given were below the WHO target of 95% in three of the four areas where childhood immunisations are measured.

• The practice always monitored the process for seeking consent and reviewed it to ensure clinicians followed relevant national guidance.

• Despite being in one of the most deprived areas of London and having a high prevalence of diabetes we saw evidence of effective performance achievement in the care and management of patients with diabetes.

• We saw evidence of effective provision of services for people whose circumstances make them vulnerable. The Substance Misuse reduction counselling service worked closely with North West London drug and alcohol team to provide a specialist in-house service which was integrated with the practice team.

We rated all population groups as good in Effective, except Families, Children and Young People which we rated as inadequate because of the low childhood immunisation rates and failure to take adequate action to improve them and Working age people which we rated as requires improvement because of the low cervical screening uptake.

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

• At our last inspection not all risks to patient safety were managed well. At this inspection we found arrangements for identifying, monitoring and managing risks to patient safety, had improved. The practice had systems to ensure safe prescribing. Staff used the clinical record system effectively to control and monitor medication reviews and re-authorisation dates for individual items on the repeat medication list.
• At our last inspection there was an ineffective system of medicines reviews for patients with long term conditions. We found medication reviews were not well coded or documented. At this inspection there was an effective system of structured medication reviews for patients with long term conditions. Medical records we looked at contained sufficiently consistent information to support the care of the patient and to enable the reviewing clinician to carry out a consultation.
• The practice had begun a programme of review and audit reviewing the quality of coding to improve consistency across the practice. At this inspection staff had reviewed and updated the Read-coding policy to ensure that clinicians and Read-coders had a standardised approach to coding in line with practice policy. (Read codes are a national standard coding system used in general practice for recording clinical information). This was a concern identified at our last inspection.
• Systems for monitoring patients prescribed high risk medicines were safe.
• The premises were clean and well maintained, we saw evidence of actions taken to prevent and control the spread of infections.
• We found evidence of quality improvement measures including clinical audits and there was evidence of action taken to change practice. Follow up audits demonstrated that learning and quality improvement had been achieved.
• The practice had a process for managing safety alerts and we saw information was communicated and actions were followed up. The practice had improved the process for recording and updating the safety alert log.
• The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services. The practice acted effectively on tasks and requests raised on the patient record system.
• Staff involved and treated patients with compassion, kindness, dignity and respect.

We rated the practice as good for providing caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

At this comprehensive inspection we rated the practice as good for providing well-led services because:

• The provider had systems to ensure oversight of safe prescribing.

• There was an effective system of structured medication reviews for patients with long term conditions. Medical records we looked at contained sufficiently consistent information to support the care of the patient and to enable the reviewing clinician to carry out a consultation.

• At our last inspection not all risks to patient safety were managed well. At this inspection we found arrangements for identifying, monitoring and managing risks to patient safety, had mostly improved. Practice leaders had developed policies and quality improvement activities to ensure safety and assure themselves they were operating as intended.

• While the provider had made improvements since our last inspection, the leadership were not managing all risks (for example, there was no protocol to keep patients informed when a medicine is used outside its licence). The practice had not followed GMC guidelines regarding giving patients sufficient information to make an informed decision.

The areas where the provider should make improvements are:

• Improve uptake of national cancer screening programmes.
• Continue to implement a programme to improve uptake of childhood immunisations.
• Improve the identification of carers to enable this group of patients to access the care and support they need.

Details of our findings and the evidence supporting our judgements 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 focused inspection at Lisson Grove Health Centre on 20 and 21 March 2019 and on 5 April 2019. This inspection was triggered by information of concern received in a report from the Coroner on 13 March 2019. We concentrated on the areas of concern raised by the Coroner and associated matters. To explore those concerns, our inspection focused on the following three key questions: Are services safe; effective; and well-led? We also inspected all six population groups under ‘effective’.

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.

At this inspection we found:

• The service did not have a clear system to ensure oversight of safe prescribing. Medical records we reviewed were not consistent in recording the medical problem, the treatment being prescribed and the length of time that treatment might persist. While not mandatory it is good practice to ensure that long term medication is linked to the medical problem in the patient record.

• We found medication reviews were not well coded or documented which meant we were not assured that patients were always receiving the correct care, treatment and monitoring for their conditions. (Read codes are a national standard coding system used in general practice for recording clinical information).

• The practice had a process for managing safety alerts and we saw information was communicated and actions were followed up. However, actions from safety alerts received were not always logged or updated on the safety alert log in a timely way.

• There were gaps in systems to assess, monitor and manage risks to patient safety.

• The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services. The practice acted effectively on tasks and requests raised on the patient record system

• There was a system for reporting and learning from serious incidents. The practice had carried out a thorough investigation into the concerns in the Coroner’s report. However, changes to the system of medication reviews were not sufficiently developed.

• There was an ineffective system of structured medicines reviews for patients with long term conditions.

• The nurse prescriber had received adequate supervision. The lead GP met weekly with the nurse prescriber but we found these supervision meetings were not documented..

• Despite being in one of the most deprived areas of London and having a high prevalence of diabetes we saw evidence of effective performance achievement in the care and management of patients with diabetes.

• Performance data on uptake rates for childhood immunisations was significantly below local and national averages in three of the four areas measured.

• There was a lack of formal governance structure in place to ensure the practice monitored all risks identified. Issues that could threaten the delivery of safe and effective care were not always identified and managed. For example, the practice was not managing all risks with respect to management reviews.

• While the practice had made some improvements since receiving the Coroner’s report, it had not appropriately addressed concerns in relation to the scheduling and recording of medication reviews.

The areas where the provider should make improvements are:

• Review systems to encourage uptake of national cancer screening programmes.
• Review the need to support staff with ongoing supervision.
• Monitor the improvements made following the Coroner’s concerns to ensure that they are consistently embedded.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care