Archived: Wainfleet Surgery

Updated 19 January 2017

Wainfleet Surgery provides primary medical services to approximately 2,167 patients residing within in Wainfleet which is a small town in Skegness and also provides services to four surrounding villages. The practice also provides services to patients residing in one care home in Wainfleet.

It is located within the area covered by Lincolnshire East Clinical Commissioning Group (CCG). It is registered with the Care Quality Commission to provide the regulated activities of; the treatment of disease, disorder and injury; diagnostic and screening procedures; family planning; maternity and midwifery services and surgical procedures.

The practice is located within a purpose built property which opened in 1991. The building is single storey and all areas are accessible to people using wheelchairs and those with other disabilities.

At the time of our inspection the practice employed two GP partners, one locum GP, one health care assistant, one senior receptionist, a team of four reception staff and a domestic. They are supported by a practice manager. The practice is open from 8am until 6.30pm Monday to Friday. Appointments are available from 9.10am until 11.20am and from 4pm until 5.50pm Monday to Friday with the exception of a Thursday afternoon when no clinic is provided by a GP. A health care assistant (HCA) provides three morning sessions per week.

The practice has General Medical Services (GMS) contract which is a contract between the GP partners and the CCG under delegated responsibilities from NHS England.

The practice has a high number of older patients and 58% of patients have a long standing health condition compared to the national average of 54%.

The practice provides on-line services for patients such as to book routine appointments, ordering repeat prescriptions and ability to view patient summary care records.

During our inspection, the practice acknowledged that following the retirement of a practice nurse in early 2016, the practice had been unable to successfully recruit additional nursing staff. This had resulted in the practice being unable to provide nursing services including clinics for patients who require chronic disease management. The practice had recruited the services of a locum practice nurse who provided approximately three sessions per month however, this nurse was not trained in chronic disease management.

When the surgery is closed GP out-of-hours services are provided by provided by Lincolnshire Community Health Services NHS Trust which can be contacted via NHS111.

Updated 19 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wainfleet Surgery on 20 and 31 October 2016.  Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, those relating to Disclosure and Barring Service checks (DBS check). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).  This included some members of staff who acted as a chaperone.  Both GP partners had not completed up to date basic life support training.

• Medication reviews were not being carried out appropriately to ensure the safe prescribing and monitoring of continued prescribing of medicines for patients. There was no evidence to show that some reviews had been carried out either face to face or by telephone consultation. Patient care records in relation to medication reviews were not found to be factually accurate and did not represent the actual care and treatment of patients.

• The practice prescribed methadone under a shared care agreement with Addaction. (a community-based treatment service for individuals experiencing the effects of problematic drug use). We were told that methadone was prescribed in two to four weekly instalments for patients on an FP10 prescription rather than an instalment (blue) prescription for controlled drugs and methadone. The GP was unsure if the correct prescriptions were being used and there was no policy or protocol in place for the prescribing of methadone.

• A GP partner carried out insertion of contraception implants. We requested the GP to provide evidence of this training immediately following inspection. The GP did provide evidence of training however, this GP was not a member of the Faculty of Sexual and Reproductive Healthcare as the GP had not completed up to date basic life support training and was therefore not accredited to carry out this procedure.

• Arrangements to safeguard children and vulnerable adults from abuse did not reflect relevant legislation and local requirements.Not all GPs had completed up to date safeguarding training.

• The practice did not hold regular, formal multi-disciplinary or team meetings, meetings that did take place were ad-hoc and were not minuted. There was no evidence of formal discussion or actions taken as a result of incidents and significant events being reported. There was no evidence of learning and communication with staff. Members of staff were not involved in significant event meetings.

• Not all risks to patients were assessed and well managed. The practice did not have an up to date fire risk assessment in place. The practice did not have other risk assessments in place to monitor the safety of the premises, staff and service users or for the control of substances hazardous to health (COSHH), legionella and infection control.

• The practice did not follow guidance in relation to cold chain management, the practice did not have a cold chain policy in place, there was no process in place to monitor temperatures at which vaccines were stored. Numerous recordings of temperatures were either above or below the minimum/maximum required temperatures.

• The practice did not maintain appropriate standards of cleanliness and hygiene. Annual infection control audits had not been undertaken and there were no action plans in place to address any improvements which may be required in relation to infection control.

• Staff had not received an annual appraisal since 2011 and there was no evidence of formal clinical supervision, mentorship and support in place for members of the clinical team.

• Patients were negative about their interactions with GPs during consultations and said they did not always feel listened to and were not always treated with compassion and dignity.

• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

• The practice had limited formal governance arrangements in place. The practice did not have an effective, documented business plan in place.

• Although some clinical audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

• The practice had a number of policies and procedures to govern activity, but some of these were either out of date, due a review or not relevant to this practice. The practice did not have a business continuity plan in place.

The areas where the provider must make improvements are:

• Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Ensure that the practice meets the requirements as detailed in the Health and Social Care Act 2008; Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

• Review governance arrangements including systems for assessing and monitoring risks and the quality of the service provision such as implementing a system of effective clinical audits. Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

• Ensure all members of staff are suitably trained and qualified including safeguarding and basic life support training. Clinicians who carry out insertion of contraceptive implants must have completed accredited training and have membership of the Faculty of Sexual and Reproductive Healthcare.

• Ensure those staff who have direct patient contact have a DBS check in place including those who act as chaperones. Ensure a system of clinical supervision/mentorship for members of the clinical team. 

• Ensure patients receive appropriate care, treatment and monitoring ensuring all required reviews are carried out including medication reviews. Ensure that an accurate, complete and contemporaneous record is maintained for every patient.

• Ensure that patient safety alerts (including MHRA) are received by the practice, and then actioned if relevant.

• Ensure that there are appropriate systems in place to properly assess and mitigate against risks including risks associated with infection prevention and control, cold chain management, legionella and fire safety.

• Ensure the safe storage and security of patient records and blank prescriptions.

The areas where the provider should make improvement are:

• Address the issues highlighted in the national GP survey in order to improve patient satisfaction, including those in relation to consultations with GPs.

• Ensure a system of appraisals is in place to ensure all members of staff receive an appraisal at least annually.

• Ensure appropriate policies and procedures are implemented, relevant to the practice ensuring all staff are aware of and understand them.

Following our inspection on 20 and 31 October 2016 we took enforcement action against the provider on the 9 November 2016. We issued an urgent notice of decision to immediately suspend their registration as a service provider (in respect of all regulated activities for which they are registered) for a period of three months. We took this action because we believed that a person would or might be exposed to the risk of harm if we did not take this action.

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

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of people with long term conditions.

• Performance for diabetes related indicators was 99% which was higher than the CCG average of 93% and the national average of 90%.(This included an exception reporting rate of 14%).

• The practice did not have nursing staff in place who were trained in chronic disease management, therefore the practice were unable to provide safe, effective management of these patients in-house. Future chronic disease management clinics such as asthma and chronic obstructive pulmonary disease (COPD) had been cancelled. This meant that structured annual reviews could not undertaken to check that patients’ health and care needs were being met.

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of families, children and young people.

• The practice’s uptake for the cervical screening programme was 75% for the period 2015-16, which was comparable to the CCG average of 74% and the national average of 74%.

• Childhood immunisation rates for the vaccinations given were mixed, some vaccination rates were lower than CCG/national averages and some vaccination rates were higher. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from 81% to 100% compared to the CCG average of 87% to 96% and five year olds from 86% to 100% compared to the CCG average of 85% to 94%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of older people.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• Patients received personalised care plans from a named GP to support continuity of care.

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of working age people (including those recently retired and students).

• The practice did not offer extended opening hours for patients who worked or students.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

• Performance for mental health related indicators was 87% which was worse than the CCG average of 89% and the national average of 93%. (This included an exception reporting rate of 33%).

• 71% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is better than the CCG average of 76% and the national average of 78%.

Updated 19 January 2017

The provider was rated as inadequate for providing a safe, effective, caring, responsive and well led service, requiring improvement for being caring. The issues identified as being inadequate overall affected all patients including this population group.

The practice is therefore rated as inadequate for the care of people whose circumstances may make them vulnerable.

• Some staff knew how to recognise signs of abuse in vulnerable adults and children, but they were not all aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. Not all GP partners had completed up to date safeguarding training.

• The practice did not hold a register of patients living in vulnerable circumstances. The practice had not worked with multi-disciplinary teams in the case management of vulnerable people.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.