Tynemouth Medical Practice

We carried out an announced comprehensive inspection at Tynemouth Medical Practice on 8 August 2019. At this inspection we followed up on breaches of regulations identified at a previous inspection on 14 February 2019.

We previously inspected Tynemouth Medical Practice on 26 July 2018, at which time we rated the practice as inadequate in all domains (Safe, Effective, Caring, Responsive and Well-led) We issued requirement notices for breaches of Regulations 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and warning notices for breaches of regulations 12 and 17 of the said regulations. We also placed the practice into special measures. A copy of our inspection report can be found on the CQC website at: .

We subsequently carried out a warning notice inspection in respect of regulations 12 and 17 on 15 November 2018, at which inspection we found that the practice had made sufficient progress to meet the warning notices. A copy of our warning notice report can be found on the CQC website at: .

Our last inspection on 14 February 2019 we followed up on the breaches of regulations found during our inspection in July 2018. We found that the practice required improvement for providing Safe care, however, it remained inadequate for all other domains. A copy of our inspection report can be found on the CQC website at: .

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.

At this inspection we have rated this practice as inadequate overall.

We rated the practice as good for providing safe services because:

• We were shown evidence of regular fire drills and alarm checks;
• All staff records we looked at for staff who needed an appraisal showed evidence of an appraisal within the last 12 months;
• Both the adult and children safeguarding policies showed evidence of having been created or reviewed within the last 12 months. Both also had future review dates set to remind the practice when the next review was due.
• The practice had completed all actions identified in its fire risk assessment.
• It had introduced a written procedure for storage of blank prescription paper.
• On review of prescriptions waiting for collection we saw no evidence of overdue medicines reviews.

We rated the practice as inadequate for providing effective services because:

• The practice’s published 2018-19 performance for childhood immunisations showed uptake had declined for all four indicators CQC regularly looks at and all four indicators were significantly below the WHO minimum target of 90% uptake;
• Uptake of the practices 2018-19 cervical cancer screening programme remained significantly below the national target of 80% uptake. Whilst, uptake of its bowel cancer screening programme had improved only marginally, and uptake of its breast cancer screening programme had declined in comparison to the practice’s performance in 2017-18;

We rated the practice as inadequate for providing effective services to families, children and young people, and working age people, requires improvement for providing effective services to people with long-term conditions, and good for providing effective services to people whose circumstances may make them vulnerable and people experiencing poor mental health.

We rated the practice as requires improvement for providing caring services because:

• The practices GP Patient survey showed improvement since our last inspection, however the results showed that two out of four indicators we looked at were below local and national averages.
• Patients we spoke to, and the majority of CQC comments cards we received, mentioned much improved levels of access and care offered by staff of the practice. However, some feedback we received from patients and some NHS Choices comments we looked at mentioned uncaring attitudes amongst staff.

We rated the practice as inadequate for providing responsive services because:

• The practice had made a number of changes, to improve access, however the results of the GP Patient Survey relating to access and timeliness of appointments showed, for all four of the indicators we looked at, the practice’s performance was below local and national averages, and one indicator remained significantly below local and national averages.
• The majority of patient comments and some recent NHS Choices comments mentioned improvements in access. However, several comments we received, and some recent NHS Choices comments complained of difficulty in getting through on the phone, and getting appointments, particularly with a patient’s preferred GP.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as requires improvement for providing well-led services because:

• Practice leaders had taken action to improve. Performance, as measured by its Quality and Outcomes Framework (QOF) outcomes showed the practice had improved in the majority of areas, in particular in regard to supporting patients suffering from mental health issues. However, in most areas its performance remained below historical local and national averages;
• The practice had taken action to improve phone access, including employing additional staff and re-organising staff rotas to ensure there were more staff in reception to deal with patients coming in to the practice and to be able to answer the phones at busy times of day. Most patient comments we received said it was now possible to get through to someone on the phone and to obtain an appointment. However, some patients commented that difficulties remained in trying to phone the practice and in obtaining an appointment.
• The practice had reviewed its staffing levels and had recruited staff at all levels across the practice including successfully recruiting: a new partner, a salaried GP, a practice nurse, and a healthcare assistant. One of the existing partners had resigned from the practice;

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

This service was placed in special measures in September 2018. Insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall. Therefore, we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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

We carried out an announced comprehensive inspection at Tynemouth Medical Practice on 14 February 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 26 July 2018. Our report following the inspection on 26 July 2018 rated the practice as inadequate in all domains (Safe, Effective, Caring, Responsive and Well-led). We issued requirement notices for breaches of Regulations 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and warning notices for breaches of regulations 12 and 17 of the said regulations. A copy of our inspection report can be found on the CQC website at: . We subsequently carried out a warning notice inspection in respect of regulations 12 and 17 on 15 November 2018, at which inspection we found that the practice had made sufficient progress to meet the warning notices. A copy of our warning notice report can be found on the CQC website at: .

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, with a rating of inadequate for effective, caring, responsive and being well-led, and requires improvement for providing safe care.

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

• The practice was unable to provide evidence of fire drills or alarm checks. Following the inspection the practice sent us evidence of fire alarm testing for the months of November 2018 and January 2019.
• Not all non-clinical staff who needed one had received an appraisal within the last 12 months. The practice advised any outstanding appraisals would be completed during the week following the inspection.
• Safeguarding policies for adults and children did not provide for safeguarding issues should the patient access advice via the practice’s online service, and there were various versions on the IT system which could put staff at risk of accessing an out of date version;
• The practice had not completed actions identified in its fire risk assessment, nor had it set review or completion dates for outstanding issues;
• The practice was securely storing blank prescription paper, however it did not make us aware of, or provide us with evidence, it had a written procedure for this purpose;
• Prescriptions waiting for collection showed evidence of overdue medicines reviews;
• The provider had failed to introduce a system to undertake regular audits of unusual prescribing, quantities, dose, formulations and strength for controlled drugs in line with national guidelines.

We rated the practice as inadequate for providing effective services because:

• Year to date performance for Quality and Outcomes Framework (QOF) showed that the practice was, in some areas, performing significantly below the local and national averages.
• Performance for childhood immunisations was significantly below the World Health Organisation (WHO) minimum target of 90%.
• Uptake of the practice’s cervical screening programme was significantly below the target 80% coverage.
• The practice’s performance for people experiencing poor mental health had declined significantly between the last data collection year (2017-18) and the current year to date (2018-19).
• There was limited evidence of quality improvement as a result of clinical audit or other quality improvement activities.

We rated the practice as inadequate for providing caring services because:

• Patient comments received via Healthwatch Haringey and NHS Choices showed that some patients experienced rude and unhelpful staff when attending the surgery.
• Patient feedback received via the National GP survey found that satisfaction levels were, in some areas, significantly below local and national averages, for example 52% of respondents answered positively about the overall experience of the practice, compared to local and national averages of 80% and 84%, respectively.

We rated the practice as inadequate for providing responsive services because:

• The practice had failed to make adjustments when patients found it hard to access services. Patient feedback via Healthwatch Haringey and NHS Choices showed access by phone or via online services had not improved since our previous inspection in July 2018.
• Although the practice told us patients were informed if there were delays, on the day of inspection we saw a patient return to the reception desk to find out why their appointment had not taken place on time.
• Patients were not always able to get an appointment with the GP of their choice.
• The practice had made no substantive progress in improving access either by phone or its online service.

We rated the practice as inadequate for providing well-led services because:

• Leaders could not show they had the capacity and skills to deliver high quality, sustainable care, for example: QOF performance showed the practice was, in some areas, performing significantly below local and national averages; this pattern was repeated in below average performance for the uptake of childhood immunisations and other clinical indicators..
• The practice was aware of phone access issues at the time of our inspection in July 2018 but had yet to develop an action plan and implement changes to provide substantive improvements for the benefit of patients.
• While the practice had a vision to provide high quality sustainable care, it was not supported by a credible strategy, for example, it had failed to recruit GPs or to recruit and retain experienced practice nurses. The practice told us of efforts it had made to recruit GPs including placing advertisements and unsuccessful applications to local initiatives.
• The practice had not reviewed and updated all policies and procedures within the last 12 months.
• It did not have a systematic programme of clinical and internal audit.
• There was limited evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Update adult and children Safeguarding policies to ensure they took account of patients accessing any online services.
• Ensure staff are able to access latest versions of all practice policies and procedures.
• Ensure staff vaccination records are maintained, and recorded on staff personnel files, in line with current guidance.
• Introduce a system to securely store and monitor blank prescription paper.
• Ensure patients waiting for an appointment are made aware when appointments are delayed.

This service was placed in special measures in September 2018. Insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall. Therefore, we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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

We previously carried out an announced comprehensive inspection at Tynemouth Medical Practice on 26 July 2018. Overall the practice was rated as inadequate and placed into special measures. We identified concerns in regard to whether the services were safe, effective, caring, responsive and well-led. We served warning notices under regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The report for the comprehensive inspection can be found on the CQC website at .

The practice sent us a plan of action to ensure the service was compliant with the requirements of the regulations.

We carried out this focussed inspection on 15 November 2018, to review the practice’s action plan, looking at the identified breaches set out in the warning notice, under the key questions of Safe and Well-led. We found the practice had made some improvements sufficient for us to consider the warning notices had been met. However, further improvement needs to be made including: in regard to patient satisfaction, governance arrangements and the use of audit and other quality improvement activities to drive performance of the practice.

We have not reviewed the ratings for the key questions or for the practice overall as this is a focussed follow-up inspection to look at whether the Warning Notices served under the Safe and Well-led key questions have been met. We will consider the practice’s ratings in all key questions and overall when we carry out a full comprehensive inspection at the end of the period of special measures.

At this inspection we found:

• The practice had introduced appropriate systems to ensure all staff received training in safeguarding of vulnerable adults and children to an appropriate level, together with training in all areas generally considered essential for staff working in GP practices. This ensured staff had the necessary skills to identify and deal with risks to patients.
• Phone access to the practice had been identified as a major contributor to patient dissatisfaction. The practice was actively working with its telecoms provider to identify the issues and to find a solution. It also planned changes to staff working patterns so more staff were available in reception to answer phones at busy times.
• Since our last inspection an experienced practice manager had been appointed to strengthen the leadership capability and capacity.
• There was a systematic approach to improvements, for example the practice had introduced a system to ensure it reviewed, learnt from, and responded appropriately to complaints.
• It was regularly checking all medical use equipment, including defibrillator and oxygen supply, to ensure it would be functional should it need to be used in a medical emergency.
• The practice had introduced a system to provide regular clinical supervision for nursing staff.

The areas where the provider should make improvements are:

• Continue to work to improve patient satisfaction for example, in regard to access to the practice.
• Ensure that clinical re-audits are completed so that identified improvements are achieved.
• Ensure that all new staff employed benefit from undergoing the practice’s induction programme.
• Continue to review and update practice governance policies.
• Develop a system for recording all meetings so decisions and learning can be shared.
• Continue to regularly review and update practice governance policies.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.