Archived: Wainfleet Surgery

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