Archived: Birstall Medical Centre

Letter from the Chief Inspector of General Practice

Birstall Medical Centre was first inspected on 21 and 29 May 2015 when the practice was rated as ‘inadequate’. The practice was placed into Special Measures in September 2015 and required to make significant improvements. An announced follow-up inspection was carried out on 15 March 2016 and we found the practice had made improvements across all five domains of safe, effective, caring, responsive and well led and was rated as ‘requires improvement’.

The practice submitted an action plan detailing how they would meet the regulations governing providers of health and social care and we carried out a further announced follow-up inspection at Birstall Medical Centre on 17 August 2016.

At our inspection, we found the practice had made improvements across all five domains of safe, effective, caring, responsive and well led. Overall the practice is rated as good.

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

• There was a system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.

• Appropriate checks were carried out before staff started employment, however there was no process to ensure nursing staff and GPs renewed their registration with the relevant professional body on an annual basis.

• Staff assessed needs and delivered care in line with current evidence based guidance.

• Staff had the skills, knowledge and experience to deliver effective care and treatment and had access to relevant training.

• Data from the national GP patient survey showed patients rated the practice lower than others for several aspects of care. The practice were aware of this and were working with the patient participation group.

• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

• The practice had a vision and clear objectives to deliver quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

• The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.

• The practice sought feedback from staff and patients, which it acted on. The patient participation group was active.

The areas where the provider should make improvement are:

• To review the system in place to ensure nursing staff and GPs renew their registration with the relevant professional body.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced follow-up inspection at Birstall Medical Centre on 15 March 2016. This inspection was a follow-up to our inspection of 21 and 29 May 2015 when the practice as rated as ‘Inadequate’. The practice was placed into Special Measures in September 2015 and required to make significant improvements. The practice submitted an action place detailing how they would meet the regulations governing providers of health and social care.

At our follow-up inspection, we found the practice had made improvements across all five domains of safe, effective, caring, responsive and well led. However, some improvement was still required and overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and investigating significant events. However, the practice acknowledged and had plans in place to improve staff awareness regarding the definition of a significant event.

• Administrative staff were unaware of local requirements in relation to safeguarding and the practice safeguarding policies did not outline the local requirements or contacts. Not all administrative staff has received safeguarding training relevant to their role.

• Not all staff with chaperone responsibilities had a Disclosure and Barring Service (DBS) check.

• The arrangements for managing medicines did not always keep people safe; this included the safe storage of prescriptions and monitoring of uncollected repeat prescriptions.

• Appropriate recruitment checks were not always carried out before employment. There was no system in place to ensure annual checks on professional registrations, where required, were carried out.

• A local agency was used for the provision of locum GPs that provided appropriate recruitment checks.

• The practice had adequate emergency equipment and medicines, and checks were carried out to ensure they were fit for use.

• Not all staff have received basic life support training.

• A comprehensive business continuity plan was in place to support the service in the event of a major disruption.

• The practice was reviewing patient care plans to ensure they assessed the needs of patients and care was delivered in line with relevant and current evidence based guidance and standards.

• Data from the Quality and Outcomes Framework showed patient outcomes were comparable to the national averages.

• Clinical audits were carried out and actions taken as a result, the practice also participated in local audit and peer review.

• The practice had reviewed and identified gaps in training needs for staff to ensure they had the right skills, knowledge and experience to deliver effective care and treatment.

• There was no active supervision for locum GPs working at the practice.

• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

• A new system had been implemented to ensure pathology results and incoming mail was reviewed and acted upon within a specified timescale.

• Training data demonstrated only one staff member had training in the Mental Capacity Act.

• Various information leaflets and posters in the patient waiting area promoted support groups to assist patients to live healthier lives.

• Data from the National GP Patient Survey showed patients rated the practice lower than others for several aspects of care.

• Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• There was a process in place to identify carers and provide relevant support.

• Practice staff were actively working with the Clinical Commissioning Group (CCG) to ensure services met the needs of its local population.

• The practice had recently changed its appointment system and we saw urgent and routine appointments were available, at both Birstall Medical Centre and Border Drive Surgery.

• Patients said they found it easy to make an appointment and there had been an improvement in making an appointment since the change in the system.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. However, informal complaints were not documented and lessons learnt.

• The practice had a short-term and medium-term strategy in place to improve the current service provision, as well as ensuring patients received high quality care.

• The practice was developing a new governance framework, which supported the delivery of the strategy and good quality care.

• Practice specific policies had been recently reviewed, implemented and were available to all staff. However, safeguarding policies did not include local authority contact details or outline what the local requirements were in relation to raising a safeguarding concern. There was also no protocol in place to support the process to contact patients who did not attend for cervical screening tests.

• There were some arrangements for identifying, recording and managing risks. However, there was no risk assessment in relation to control of substances hazardous to health (COSHH) products. The practice had not identified the potential risk to prescriptions not securely stored, or the risk to patients if a repeat prescription was not collected. Not all staff with chaperone responsibilities had appropriate Disclosure and Barring Service (DBS) checks.

• There was a leadership structure in place, which was still undergoing review by the practice. Staff felt supported by management and were positive about the changes to the service.

• The provider was aware of and complied with the requirements of the Duty of Candour.

• The practice was unable to demonstrate any actions taken as a result of patient surveys or feedback. However, had plans in place to introduce local patient surveys involving the patient participation group (PPG).

• Limited progress was made by the practice as a result of feedback from the PPG, however the PPG were hopeful with the new practice management team, feedback would be acted on.

The areas where the provider must make improvements are:

• Ensure policies and procedures contain relevant and necessary information, and they support current processes and systems.

• Ensure staff carry out relevant and mandatory training.

• Ensure Disclosure and Barring Service (DBS) checks are carried out on staff members with chaperone responsibilities.

• Ensure recruitment checks are carried out before employment and annual checks on professional registration statuses are carried out.

• The safe storage of prescriptions.

• Implement a process to review uncollected repeat prescriptions.

• Provide supervision to locum GPs working at the practice.

• Review data from the National GP Patient Survey and take action where necessary.

• Ensure all appropriate risk assessments are carried out.

• Review patient feedback and patient surveys to take action to improve services provided.

In addition the provider should:

• Ensure staff are aware of what constitutes a significant event so these can be reported and investigated thoroughly.

• Continue to review patient care plans to ensure care is provided in line with relevant and current evidence based guidance and standards.

• Document, record and investigate informal complaints.

• Finalise the governance framework to support the delivery of the strategies and good quality care.

• Finalise the leadership structure and continue to involve all staff members in discussions.

• Improve the communication with the PPG and act on feedback.

I confirm that this practice has improved sufficiently to be rated ‘Requires improvement’ overall. The practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice