Background to this inspection
Updated
26 July 2021
Brailsford and Hulland Medical Practice is a rural, dispensing practice located in Southern Derbyshire in the Peak District at:
The Green
Brailsford
Ashbourne
Derbyshire
DE6 3BX
The practice has a branch practice at:
Hulland Ward
Main Road
Hulland Ward
Ashbourne
Derbyshire
DE6 3EA
We visited both practices as part of this inspection.
The provider is registered with the CQC as a partnership to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. Patients can access services at either practice.
The practice is situated within the NHS Derby and Derbyshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 6,025 patients. This is part of a contract held with NHS England. The practice is part of Derbyshire Dales Primary Care Network, a wider network of 13 GP practices that work collaboratively to deliver primary care services.
Information published by Public Health England shows that deprivation within the practice population group is in the nineth lowest decile (nine of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is predominantly white at 98% of the registered patients, with estimates of 0.8% mixed race, 0.9% Asian, 0.2% Black and 0.1% other groups.
The age distribution of the practice population demonstrates a higher proportion of older patients, and lower numbers of younger patients compared to local and national averages:
- The percentage of older people registered with the practice is 29.1% which is above the CCG average of 20.2%, and the national average of 17.6%.
- The percentage of young people registered with the practice is 16.1% which below the CCG average of 19.5%, and the national average of 20.2%.
There is a team of two GP partners, two salaried GPs, a practice nurse and two healthcare assistants. They provide cover at both practices. The team are supported by a temporary practice manager, an operations manager, a team of dispensers and a team of receptionists and administration staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Out of hours services are provided by Derbyshire Health United (DHU).
Updated
26 July 2021
We carried out an announced inspection at Brailsford and Hulland Medical Practice on 23 and 24 June 2021. Overall, the practice is rated as inadequate. It is rated as:
- Inadequate for providing safe care and treatment
- Requires improvement for providing effective care
- Good for caring
- Requires improvement for providing responsive care
- Inadequate for well-led
Following our previous inspection on 30 November 2015, the practice was rated Good overall and for all key questions. The full report for the previous inspection can be found by selecting the ‘all reports’ link for Brailsford and Hulland Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to follow up on:
- Concerns shared with the CQC, prior to the inspection, regarding the safe care and treatment of patients and overall governance of the service. We were aware that the practice has been attempting to manage a period of considerable organisational challenge.
- Key questions safe, effective, caring, responsive and well-led.
- Two best practice recommendations identified at our previous inspection:
- Develop and implement how their vision for the future of the practice is shared with staff.
- Improve the arrangements for cascading learning from significant events to try and prevent recurrence.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
Our findings
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 inadequate overall and requires improvement for all population groups.
We rated the practice as inadequate for providing safe care and treatment. This is because:
- Systems to follow up frequent attenders to A&E or children who did not attend appointments in secondary care were not in place. Systems were not in place to share information regarding vulnerable adults with the ambulance service.
- Recruitment checks were not carried out in accordance with regulations. Evidence that all staff had the appropriate vaccination and immunity to potential health care acquired infections was not available.
- Where risk assessments had been completed it was not always clear if the required action had been taken to mitigate risks.
- Effective infection prevention and control processes were not in place.
- Processes for the safe handling of requests for repeat medicines for long-term conditions and to monitor the health of patients prescribed some high-risk medicines were not effective. Blank prescriptions were not kept securely, or their use monitored in line with national guidance, at the branch practice.
- Systems for recording significant events did not always identify the learning, actions or trends in significant events. There were missed opportunities to raise and analyse significant events.
- The provider could not demonstrate that Medicines and Healthcare products Regulatory Agency (MHRA) alerts were incorporated into clinical practice.
We rated the practice as requires improvement for providing an effective service. This is because:
- Health and medicine reviews for patients with long-term conditions had not always been completed in line with National Institute for Health and Care Excellence (NICE) guidance.
- Quality audits had been completed by the provider however, it was not always clear it the actions identified had been implemented and if so, what the impact had been.
- The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles. There was no overarching system in place to monitor compliance with staff training.
We rated the practice as good for caring. This is because:
- Staff treated patients with kindness, respect and compassion.
- There were systems in place to support carers.
We rated the practice as requires improvement for responsive because:
- Information about how to complain was not readily available and staff did not have access to a complaint’s policy. The practice could not always demonstrate learning from complaints, and we found that opportunities to record complaints had been missed.
We rated the practice as inadequate for providing a well-led service. This is because:
- Leaders could not demonstrate that they had the capacity and skills to address the challenges within the practice. However, they had insight into their own limitations and arranged for care taking arrangements to be put in place to support the governance of the practice and the safety of patients.
- A clear vision or credible strategy to provide high quality sustainable care was not in place.
- Not all staff felt able to raise concerns. Some staff told us that they felt undervalued, unsupported and unhappy at work. Staff well-being had been affected resulting in staff resignations and staff on long-term sick leave.
- Policies to support the governance and safe running of the practice were not available to staff. Policies were not always reviewed in line with planned review dates.
- Effective governance structures and systems were not in place. This included policies and systems to manage the governance and oversight of remote services.
- Effective processes for managing risks were not in place.
We found two breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
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.
We found serious concerns about patient safety. We told the practice to submit an action plan by 30 June 2021 to detail how the serious concerns that put patients at risk would be addressed. An action plan was submitted. Care taking arrangements were put in place on 25 June 2021 and the provider informed us that they would submit an application to cancel their registration with the Care Quality Commission. If these measures had not been put in place, we would have taken greater enforcement action.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care