Windmill Health Centre

This practice is rated as Good overall and as Requires Improvement for the provision of safe services. In addition, we rated all population groups as Good except for Families, children and young people which we rated Requires Improvement for providing effective services.

This practice was previously inspected in October 2018 when it was rated as Inadequate overall and placed in special measures. In addition, the practice had received a focused inspection in February 2019 to assess compliance with breaches identified during the October 2018 inspection. This focused inspection was not rated.

At the inspection, carried out in October 2018 the practice was rated as Inadequate and placed in special measures because:

• The provider did not maintain oversight of staff training and could not be assured that all staff had undertaken safeguarding training relevant to their role. Not all relevant staff had a DBS check on file or evidence of references, including a GP. Staff joining the practice since 2016 had not been offered fire safety training.
• Locum staff were sourced through recognised agencies. However; there was no practice policy for what information and checks were required prior to appointment. Information supplied by the agencies that we reviewed during the inspection, did not consistently evidence safeguarding training or professional indemnity.
• The safeguarding policies were undated and limited in scope.
• The system to manage infection prevention and control (IPC) was not effective.
• Patient Group Directions (PGDs) were not correctly authorised.
• Prescription stationery was not monitored by the provider for audit and security purposes.
• Resuscitation guidance stored with emergency equipment was out of date.
• Recommended monitoring checks for the risk of legionella were not undertaken.
• Weekly fire alarm tests had not been undertaken for a period of six months.
• There was a backlog of patient records that required summarising.
• Significant event recording was ineffective as records lacked sufficient detail to allow for improvements to be identified and shared.
• The provider could not demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
• Staff induction and appraisal was undertaken informally and was not consistently documented across the team.

• Staff did not have a documented induction plan and some staff were overdue their annual appraisal.
• The provider did not have a policy on occupational health or lone working. Adult and child safeguarding policies were undated and limited in scope.
• Outcomes and discussions of staff and clinical meetings were not always documented. Those that were taken were limited in scope and did not provide assurance that matters raised had been addressed or carried forward.

Requirement and warning notices were served at this time to rectify breaches in legal requirements in relation to Regulation 12(1), Safe care and treatment, Regulation 17(1), Good governance and Regulation 19(3) Fit and proper persons employed.

At the next inspection, carried out in February 2019, which was made to confirm that the provider had responded to warning notices from the October 2018 inspection we found that the provider had made the required improvements in most areas identified during the previous inspection. However, the provider had not sufficiently acted on the findings of the most recent Infection Control and Prevention (IPC) audit and we found that the practice premises were in a poor state of repair. We saw that the condition of the building had deteriorated since our last inspection. In response to these breaches a further warning notice was served in relation to a breach of Regulation 15 (1) and (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with a compliance date for completion of 5 April 2019.

At this inspection carried out on 30 May 2019, we found that the provider had made significant progress and addressed most of the areas highlighted for action. However, structural improvements had only partially been completed and works were ongoing to improve the condition of the consultation and treatment rooms.

We based our judgement of the quality of care at the 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 Good overall, and as Requires Improvement for the provision of safe services. In addition, we rated all population groups as Good except for Families, children and young people which we rated Requires Improvement for providing effective services.

We rated the practice as requires improvement for the provision of safe services because:

• The improvements required to the physical condition of the consultation and treatment rooms had not been fully completed. The provider had an action plan in place, had prioritised the works required, and was working to complete these.
• The provider was not fully assured that staff immunity status checks had been carried out in relation to measles, mumps and rubella, and varicella.

We rated the practice requires improvement for providing effective services to Families, children and young people because:

• Child immunisation performance was below the minimum target of 90%.

At this inspection we found:

• The provider had made some improvements to the structural condition of the practice. However, this had not been fully completed and work was still ongoing to achieve compliance to the necessary standard required.
• The practice had clear systems in place to manage risk and keep people safeguarded from abuse. This included training staff in supporting patients who had suffered from domestic abuse and hosting a weekly support clinic for domestic abuse patients.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice worked well with other stakeholders to deliver and coordinate care.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice had put in place a support programme for their Advanced Care Practitioner.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure all premises and equipment used by the service provider is fit for use.

The areas where the provider should make improvements are:

• Improve staff immunity status checks to give assurance that necessary checks have been carried out in relation to measles, mumps and rubella, and varicella.
• Continue to reduce the small backlog of patient correspondence which needed scanning and placing on the patient record.
• Work to improve child immunisation performance.
• Review and improve performance in relation to the number of cancer reviews carried out with patients within six months of diagnosis.

I am taking the service out of special measures. This recognises the improvements made to the quality of care provided by the service. Details of our findings and evidence supporting our decisions and ratings are set out in the evidence table.

Dr Rosie Benneyworth BE BS BMed Sci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Windmill Health Centre on 2 October 2018. The overall rating for the practice was inadequate and the service was placed into special measures. The full comprehensive report for the October 2018 can be found by selecting the ‘all reports’ link for Windmill Health Centre on our website at .

This inspection was an announced focused inspection carried out on 11 February 2019 to confirm that the practice had responded to the warning notices dated 19 October 2018 and met the legal requirements in relation to breaches of Regulation 12(1), Safe Care and Treatment and Regulation 17(1), Good governance identified in our previous inspection on 2 October 2018. The provider was required to be compliant with the matters documented in the warning notices relating to Regulation 12 by 28 December 2018 and those relating to Regulation 17 by 22 January 2019.

This report covers our findings in relation to those requirements.

Our key findings were as follows:

• The provider had made the required improvements in most areas identified during the previous inspection. However, the provider had not sufficiently acted on the findings of the most recent Infection Control and Prevention (IPC) audit and we found that the practice premises were poorly maintained. We saw that the condition of the building had deteriorated since our last inspection.
• Resuscitation guidelines stored with emergency medical equipment had been updated and reflected the most current guidance.
• The recommendations of the 2016 legionella risk assessment had been acted upon with relevant staff trained and evidence seen of recommended water checks being made on a regular basis.
• Staff with responsibility for IPC across the practice had received relevant update training and the IPC policy had been reviewed.
• Significant event recording and the provider’s approach to learning from these events had been reviewed. We saw that they were documented, discussed and acted upon by the senior management team.
• Verbal complaints were recorded and we saw that all complainants were advised in writing of their right to refer complaints to the Parliamentary and Health Service Ombudsman if they were not satisfied with the provider’s response.
• A staff training matrix had been developed and we saw that mandatory training requirements had been established by the provider and were being implemented across the staff team.
• We saw that oversight of prescription stationary security had been reviewed and was now safely managed. The provider also told us that patient group directions (PGDs) had been reviewed and systems were now in place to ensure they were correctly authorised.
• Newly appointed staff were given an induction plan and their progress was documented. All relevant staff had received an appraisal in the last 12 months.
• Clinical and staff meetings were appropriately documented.
• Policies relating to staff occupational health and lone working had been implemented.

The area where the provider should make improvements are:

• Continue to ensure that the backlog of summarising records is addressed and cleared by 31st March 2019.

The area where the provider must make improvements as they are in breach of regulations are:

• The provider must ensure all premises and equipment used by the service provider is fit for use and maintain appropriate standards of hygiene for premises and equipment.

We are taking further action in line with our enforcement processes. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice