Rudgwick Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rudgwick Medical Centre on 5 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

The practice was also issued with Warning Notices and a further focused inspection was carried out on 17 May 2017 to ensure that the practice had complied with the legal requirements of the Warning Notices. We found that these notices had been met.

The full comprehensive report on the 5 January 2017 and 17 May 2017 inspections can be found by selecting the ‘all reports’ link for Rudgwick Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 28 September 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had a process in place for reporting incidents and near misses. Staff understood their responsibilities to raise concerns, and to report incidents and near misses. The provider had taken steps to improve their review system. Investigations relating to significant events were now comprehensively maintained and discussions, learning and action to ensure improvements were documented.

• Risks to patients were now assessed and well managed. There was a risk assessment process within the practice and management of risks was prioritised. Risk had now been assessed relating to areas such as legionella and control of substances hazardous to health.

• Staff had received fire safety training and the practice now undertook fire drills. Action relating to fire risks had been taken following a fire incident in November 2016.

• The practice had policies in place relating to safeguarding children and vulnerable adults, staff had received training at an appropriate level and were aware of who the safeguarding lead was.

• The practice infection control policy was up to date and infection control lead had been appointed. Cleaning schedules were now in place together with a comprehensive infection control audit.

• There was a system in place for responding to and managing complaints, records relating to complaints demonstrated a thorough investigation and action to mitigate any associated risks.

• Recruitment checks were in place and files included satisfactory information about conduct in previous work for staff prior to commencing their employment.

• All clinical staff, including those undertaking chaperone duties had a Disclosure and Barring Service check in place; the practice had now assessed the risks of not having checks in place for all non-clinical posts.

• Data showed patient outcomes were comparable to or above the national average. The practice had undertaken clinical audits and these had been full cycle.

• The practice had a number of policies and procedures to govern activity, a number had been reviewed and updated.

• Controlled drugs were stored securely. Systems were in place to ensure regular disposal of controlled drugs returned by patients. Monthly audits of controlled drugs were consistently undertaken in accordance with their own policy. The practice had established a relationship with the police liaison officer to ensure timely destruction of unwanted controlled drugs.

• The practice had introduced a cold chain policy for the safe storage and management of medicines requiring refrigeration.

• The practice had identified areas of mandatory training for each role within the practice. Attendance at training such as safeguarding, fire, health and safety, infection control and information governance was consistent and there were no significant gaps in training records.

• The practice had a clear leadership structure in all areas and there was leadership capacity and formal governance arrangements had significantly improved.

• An appraisal system was in place and all clinical and non-clinical staff had received a recent appraisal that included a review of training and development.

• Patients said they were treated with compassion, dignity and respect. Appointment availability was good and staff listened to and involved them in their care and treatment.
• The practice sought help from the Royal College of General Practitioners (RCGP) following the inspection on 5 January 2017 to assist with their action plan.

However, there were also areas of practice where the provider needs to make improvements.

In addition the provider should:

• Review and keep their significant events log up to date to ensure all actions are captured to aid further analysis of themes and audit of the significant events system.

• Continue to review patient outcomes for long term conditions such as those with high exception reporting within the practice in relation to asthma, chronic obstructive pulmonary disease and cancer indicators.

• Continue to monitor the number of carers known to the practice to ensure they identify any new and existing carers.
• Review the provision of extended hours in order to enhance the service provided to patients who work.
• Continue to sustain and embed the improvements made over time

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

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 comprehensive inspection at Rudgwick Medical Centre on 5 January 2017. The overall rating for the practice was inadequate. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Rudgwick Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focussed inspection carried out on 17 May 2017 to confirm that the practice was compliant with warning notices issued following the January 2017 inspection. The warning notices were issued against regulation 12 (1) (safe care and treatment) and regulation 17 (1) (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report covers our findings in relation to those requirements. Our findings reflect that the practice had taken action against the warning notices issued and that they were compliant with the warning notices. The ratings remain unchanged from the January 2016 inspection as the purpose of the May 2017 inspection was to review compliance against the warning notices issued.

Our key findings were as follows:

• The practice had a clear, timely action plan in place for how they were addressing the areas of practice activity where improvements were needed.
• The practice had made improvements to recruitment processes and we saw that appropriate employment checks had been carried out on staff including references.
• There was evidence of improvements made to incident reporting, discussion and learning.
• The practice was developing a programme of clinical audit.
• The practice had taken action to improve infection control practices including identifying clear leadership and carrying out an infection control audit.
• The practice had made improvements to risk management processes with evidence of risk assessments and appropriate actions in relation to health and safety, fire safety, legionella and the environment.
• The practice had taken action to review and update policies and procedures including those relating to the dispensary, infection control and health and safety.
• The practice had made improvements in the dispensary in relation to the management and destruction of controlled drugs and relevant record keeping. They had engaged with an accountable officer for the destruction of controlled drugs and were working with them to improve practice and provide training for dispensary staff.
• There was evidence of improved communication and cascading of information and learning across staff teams and the organisation as a whole.
• There was evidence of improved leadership in specific identified areas such as infection control and safeguarding.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rudgwick Medical Centre on 5 January 2017. Overall the practice is rated as inadequate overall as they are rated as inadequate in providing safe and well-led services. They are rated as requires improvement in effective and responsive services and good in caring.

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

• The practice had a process in place for reporting incidents and near misses. Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. Records relating to significant events were not comprehensively maintained and discussions, learning and action to ensure improvements was not always clear. There was no evidence of learning and communication with staff.

• Risks to patients were not assessed or well managed. There was no risk assessment process within the practice and management of risks was not a priority. Risk had not been assessed relating to areas such as legionella and control of substances hazardous to health.
• A fire safety incident had shown that not all staff were clear about their responsibilities in the event of a fire. Minimal staff had attended fire safety training and the practice did not undertake fire drills. Action relating to these areas had not been taken following a fire incident in November 2016.
• The practice had policies in place relating to safeguarding children and vulnerable adults, however not all staff had received training at an appropriate level and staff were not always aware of who the safeguarding lead was.
• The practice infection control policy was ten years out of date for review, there were no cleaning schedules in place, there was no identified infection control lead and infection control audits had not been carried out.
• There was a system in place for responding to and managing complaints, however records relating to complaints did not always demonstrate a thorough investigation or action to mitigate any associated risks. There was no evidence of a review of complaints to identify themes or trends and no record of communication with relevant staff to ensure improvements.
• Recruitment checks were in place; however some staff files did not include satisfactory information about conduct in previous work for staff prior to commencing in place.
• All clinical staff, including those undertaking chaperone duties had a Disclosure and Barring Service check in place; however the practice had not assessed the risks of not having checks in place for all non-clinical posts.
• Data showed patient outcomes were comparable to the national average. Some clinical audits had been carried out although these were not always full cycle.
• The practice had a number of policies and procedures to govern activity, but many were overdue a review.
• Controlled medicines in the dispensary were stored securely, however there was no system in place to ensure regular disposal of controlled medicines returned by patients. Monthly audits of controlled medicines stored in the dispensary were not consistently undertaken in accordance with their own policy.
• The practice did not have a cold chain policy in place for the safe storage and management of medicines requiring refrigeration.
• The practice had not identified areas of mandatory training for each role within the practice. Attendance at training such as safeguarding, fire, health and safety, infection control and information governance was not consistent and there were significant gaps in training records.

• The practice did not have a clear leadership structure in all areas and there was insufficient leadership capacity and limited formal governance arrangements. 

• Nursing staff had not received an appraisal in the last 12 months.
• Patients said they were treated with compassion, dignity and respect.

The areas where the provider must make improvements are:

• Investigate safety incidents and complaints thoroughly and ensure that comprehensive records are maintained. Ensure that safety incidents and complaints are discussed with the wider practice team and that learning from these discussions is cascaded, leading to improved practice.

• Ensure that there is an accessible health and safety policy and that risk assessments are carried out and acted upon. Including for fire safety, chemicals hazardous to health and management of legionella.

• Ensure that all staff attend fire safety training, that regular fire drills are carried out and where necessary, improvements in practice are demonstrated as a result.

• Review and update all practice policies, ensuring that policies are accessible to all staff.

• Ensure that audits of controlled medicines are carried out regularly in accordance with the practice policy and that records in the controlled drug register are maintained in line with controlled drug regulations.

• Develop a cold chain policy and ensure that all staff monitoring the temperature of the vaccination fridge are appropriately trained and understand acceptable temperature ranges and the action to be taken if these are outside of range.

• Ensure that infection control protocols are up to date, that there is an identified and trained infection control lead within the practice, that annual infection control audits are undertaken and that all staff attend infection control training.
• Ensure that all nursing staff have annual appraisals and regular clinical supervision.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Identify training requirements for each staff role and ensure this is carried out. Ensure that locum GP records include evidence of up to date appropriate training such as for basic life support.

In addition the provider should:

• Review patient outcomes for long term conditions such as those with high exception reporting within the practice in relation to asthma, chronic obstructive pulmonary disease and cancer indicators.
• Ensure that all clinical audits are full cycle, demonstrating improvements and that there is evidence of shared learning as a result.

• Ensure a risk assessment is carried out for all roles within the practice to identify which roles should be subject to a DBS (Disclosure and Barring Service) check.

• Review childhood immunisation rates where these are below average.

• Improve processes for the identification of carers in view of current rate being less than 1%.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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