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Albany Practice Requires improvement

Reports


Inspection carried out on 13 April 2021

During a routine inspection

We carried out an announced inspection at Albany Practice on 13 April 2021. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective – Requires improvement

Caring - Requires improvement

Responsive - Requires improvement

Well-led - Good

Following our previous inspection on 24 September and 14 October 2020, the practice was rated Inadequate overall and for providing safe, effective, responsive and well-led services and Requires Improvement for providing a caring service. We imposed 20 urgent conditions on the provider’s registration with CQC and we placed the practice in special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Albany 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:

  • All key questions
  • The conditions imposed on the provider’s registration

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 some staff interviews using video conferencing
  • Completing 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 Requires Improvement overall and in the effective, caring and responsive key questions and all population groups. The safe and well-led key questions are rated Good.

We found that:

  • The practice had implemented a detailed action plan and made significant progress to address many of the concerns identified at our previous inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs. However, the systems and processes to improve uptake rates for cervical screening and childhood immunisations over the past two years were not effective.
  • Staff reported treating patients with kindness and respect and involved them in decisions about their care. However, feedback from the National GP Patient Survey showed patient satisfaction with the service was significantly below local and national averages. The practice was aware of this negative feedback and was in the process of addressing these concerns to improve patient satisfaction.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However, performance data prior to the pandemic showed patients could not always access care and treatment in a timely way. This area was identified as a priority for the practice and they had implemented some changes in a short space of time.
  • The practice had recently expanded their management structure to promote the delivery of high-quality, person-centre care. As these changes were newly implemented, the practice could not yet demonstrate the impact these changes had on the service.

Whilst we found no breaches of regulations, the provider should:

  • Continue to mitigate the risks associated with fire safety and fixed electrical installation.
  • Continue to review the systems and processes to improve uptake rates for cervical cancer screening and childhood immunisations
  • Provide information on the types of appointments offered on the practice website
  • Continue to review patient feedback in all areas and develop the patient participation group
  • Enable staff to have access to a Freedom to Speak Up Guardian

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

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

Inspection carried out on 24 September 2020 and 14 October 2020

During a routine inspection

We carried out an announced comprehensive inspection at Albany Practice on 24 September and 14 October 2020.

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. We requested information from the provider on 11 September 2020, undertook a remote clinical records review and desk-based inspection on 24 September, and a short on-site visit at the practice premises on 14 October 2020. As part of the desk-based inspection a GP specialist advisor and a member of the CQC medicines team spoke with the Lead GP and two clinical pharmacists by telephone and we reviewed documentary evidence submitted by the practice.

The practice was previously inspected on 09 October 2019. Following this inspection, the practice was rated requires improvement overall and in all key questions and patient population groups. We issued requirement notices for breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance).

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.

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

  • The practice did not have clear systems and processes to keep patients safe
  • The practice did not have appropriate systems in place for the safe management of medicines, including those which require additional monitoring
  • Safeguarding systems and processes including training for staff
  • Recruitment checks
  • Not all staff had been given guidance on identifying deteriorating or acutely unwell patients
  • The practice did not learn and make improvements when things went wrong

We found the provider had made some improvements regarding:

  • The management of medicines used to treat auto immune conditions
  • Emergency medicines and equipment
  • Cold chain management
  • Infection prevention and control
  • A safe system to monitor uncollected prescriptions.
  • The management of patient group directions (PGDs).

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

  • The practice was unable to show that clinical staff had the skills, knowledge and experience to carry out their roles
  • Clinical supervision for staff
  • Appraisals for clinical staff

These inadequate areas impacted all population groups and so we have rated all population groups as inadequate.

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

  • There was a lack of effective action to address deteriorating results in the national GP patient survey indicators, which had deteriorated since our last inspection.
  • Patients were not always given appropriate information in a timely way.

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

  • There was a lack of effective action to address deteriorating results in the national GP patient survey indicators, which had deteriorated since our last inspection and were considerably below local and national averages.
  • We did not see evidence of a complaints policy or that complaints were used to drive continuous learning and improvement.

These inadequate areas impacted all population groups and so we have rated all population groups as inadequate.

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

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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).

The areas where the provider should make improvements are:

  • Continue to undertake regular fire drills in accordance with the legislation.
  • Continue to maintain oversight regarding risk assessments and follow up action points undertaken by property services.
  • Continue to undertake and document regular internal infection prevention and control audits.

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.

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

Inspection carried out on 09 Oct 2019

During a routine inspection

We carried out an announced comprehensive inspection at Albany Practice on 09 October 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us.

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 requires improvement overall and requires improvement for all population groups.

We found that:

  • The systems and processes in place to keep patients safe required improvement. For example, the practice did not have a robust system in place to manage medicines and safety alerts.
  • Patients received effective care and treatment that met their needs; however, some of the staff had not completed training appropriate to their role.
  • The uptake for childhood immunisations and cervical screening were below average.
  • Staff dealt with patients with kindness and respect and patients we spoke to indicated that they were involved in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. However, some of the patients we spoke to indicated they had to wait up to three weeks to obtain an appointment.
  • The results of the national GP patient survey indicated that the practice scored below average in relation to patient satisfaction of the service.
  • The governance systems in place for safe and effective running of the practice required improvement.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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).

The areas where the provider should make improvements are:

  • Staff complete training appropriate to their role.
  • Provide protected learning time for staff.
  • Consider ways to improve uptake for childhood immunisations, cervical screening and learning disability health checks.

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

Inspection carried out on 28 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Albany Practice on 28 January 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, not all adverse events were investigated as a significant event and there was limited evidence of shared learning for these incidents.
  • Risks to patients were assessed and generally well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said staff were friendly, helpful, caring, polite and that they felt involved in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • Improve the documentation of actions taken from adverse events that are not investigated as a full significant event.

  • Complete training for all staff undertaking chaperone duties.

  • Ensure that procedures for monitoring fridge temperatures used to store vaccines and medicines are consistently followed.
  • Review the storage arrangements of emergency medicines and equipment to ensure timely access in the event of a medical emergency and improve the monitoring of medical consumables to ensure they are in date and fit for purpose. Ensure a serial log is maintained for all hand written prescriptions.
  • Ensure there is a system for shared learning of new guidelines and protocols.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice