Forrester Street Medical Centre

We previously carried out an announced comprehensive inspection at Forrester Street Medical Centre on 11 July 2019 as part of our inspection programme. The practice was rated inadequate, placed into special measures and warning notices in relation to safe care and treatment and good governance were issued. We carried out an announced focused inspection at Forrester Street Medical Centre on 29 October 2019 to ensure that the issues identified in the warning notices had been addressed. The reports on the July 2019 and October 2019 inspections can be found by selecting the ‘all reports’ link for Forrester Street Medical Centre on our website at cqc.org.uk.

We carried out an announced comprehensive inspection at Forrester Street Medical Centre on 4 February 2020. At this inspection we followed up on breaches of regulations identified at the previous comprehensive inspection on 11 July 2019.

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.
• information from the provider, patients and other organisations.

We have rated this practice as requires improvement overall and in safe, effective and responsive and good in caring and well-led. We rated each population group as good except for people with long-term conditions, families, children and young people and working age people which we rated as requires improvement in the effective domain. This was because the quality indicators were below average and targets for childhood immunisation uptake and cervical cancer screening had not been met. We rated all population groups as requires improvement in the responsive domain as although improvements had been made, continuing concerns regarding timely access to the service affected all population groups.

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

• Recruitment procedures were not being effectively implemented as not all of the required recruitment checks had been obtained prior to all staff starting employment or were available on file. Risk assessments had not been completed to mitigate any risks.

We rated the practice as requires improvement in providing effective services because:

• The quality indicators for diabetes and other long-term conditions were significantly below the local and national averages.
• The practice had not met the minimum 90% target for three of the four childhood immunisation uptake indicators.
• Cervical cancer screening rates were significantly below the national target.
• Screening rates for breast cancer and bowel cancer were below local and national averages.

We rated the practice as good in providing caring services because:

• Staff treated patients with kindness, respect and compassion.
• The practice respected patients’ privacy and dignity.

We rated the practice as requires improvement in providing responsive services because:

• Although a new telephone system had been installed, some patients continued to report challenges accessing the practice by telephone.
• Although patients had access to a range of appointments with different clinicians, some patients continued to report that they were unable to get appointments.
• There had been delays to completion of the planned alterations to the premises, which had only recently commenced.

We rated the practice as good in providing well-led services because:

• The introduction of a lead GP and an experienced practice manager had improved the management of the practice.
• Staff morale continued to improve. Staff told us that the practice continued to develop and improve under the leadership of the GP partner and new practice manager. Staff told us that they were approachable and provided support when required.
• Governance structures and systems were being used effectively.
• Effective communication had been maintained through structured meetings, including the daily huddle and weekly clinical meetings.
• Processes for managing risks, issues and performance were in place. The performance of clinical staff was assessed and recorded.
• Systems were in place to safeguard children and vulnerable adults from harm. Systems were in place to follow up children who failed to attend for appointments, and regular discussion took place with the health visitors.
• The planned programme of clinical and internal audit had been maintained and demonstrated quality improvements for patients.
• The practice manager had oversight of staff training, and staff were up to date with their essential training.
• Staffing levels had improved and staff were clear about their roles and responsibilities on a daily basis.
• The practice had appointed additional clinical staff in allied health care roles, and offered video consultations, which provided a range of different appointments for patients.

The areas where the provider must make improvements are:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Record the action taken, completion date and sign off on infection control audits to evidence any appropriate action has been taken.
• Continue to address the backlog in summarising patient notes.
• Continue to implement strategies to improve the management and care provided to patients with long-term conditions.
• Explore and implement strategies to increase the uptake of childhood immunisations.
• Explore and implement strategies to increase the uptake of cervical cancer screening, breast and bowel cancer screening.
• Explore and implement strategies to maintain patient confidentiality in the main waiting area.
• Assess the effectiveness of the strategies implemented to improve patient satisfaction with telephone access and appointments.
• Information regarding how to complain should be readily available for patients to access within the practice.
• Record the response to complaints, including detailing of how to escalate the complaint if required.

I confirm that this practice has improved sufficiently to be rated Requires Improvement overall. Therefore, I am taking this service out of special measures.

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 Forrester Street Medical Centre on 11 July 2019 as part of our inspection programme. The practice was rated inadequate, placed into special measures and warning notices in relation to safe care and treatment and good governance were issued. The full comprehensive report on the July 2019 inspection can be found by selecting the ‘all reports’ link for Forrester Street Medical Centre on our website at www.cqc.org.uk.

We carried out an announced focused inspection at Forrester Street Medical Centre on 29 October 2019 to ensure that the issues identified in the warning notices had been addressed. This report only covers our findings in relation to the warning notice.

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

At this inspection, we found that the provider had satisfactorily addressed the issues identified in the warning notices. We specifically found that:

• The management and leadership of the practice had been improved by the introduction of a lead GP and experienced practice manager.
• Staff morale had improved. Staff told us that the introduction of the GP partner and practice manager had brought about improvements at the practice. Staff told us that they were approachable and provided support when required.
• Governance structures and systems were being used effectively and were embedding within the practice.
• Communication had improved through the introduction of structured meetings, including the daily huddle and weekly clinical meetings.
• Processes for managing risks, issues and performance had been set and showed initial signs they were embedded. The performance of clinical staff, including locum GPs and the allied health professional, was being assessed by the lead GP. However, this was only formally documented for the allied health professional and not the locum GPs.

• Improvements had been made around safeguarding children and vulnerable adults. Staff were appropriately trained and aware of the safeguarding lead. Systems were in place to follow up children who failed to attend for appointments, and regular discussion took place with the health visitors.

• A programme of clinical and internal audit had been introduced. A number of audits had been introduced which demonstrated improvements for patients.
• The practice manager had oversight of staff training, and staff were up to date with their essential training.
• Outstanding risk assessments had been completed, although data products sheets were not available for substances hazardous to health.
• The provider had reviewed non-clinical staffing levels and re-organised administrative and reception work. Staff were clear about their roles and responsibilities on a daily basis. The re-organisation of the work on the reception desk had resulted in patients being attended to more quickly and a calmer waiting area.
• The practice appointed additional clinical staff in allied health care roles, resulting in additional appointments for patients.

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

• Document clinical supervision between the lead GP and clinicians.
• Obtain the data product sheets for all substances hazardous to health in use.

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 a short notice announced comprehensive inspection at Forrester Street Medical Centre on 11 July 2019 because of information of concern received about the service.

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.

During the factual accuracy period the provider sent us further information relating to safety concerns we raised. However, the information did not address all of the concerns and did not affect the judgement or rating.

We have rated this practice as inadequate overall.

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

• The management of safety systems was not effective particularly in relation to safeguarding, staff training, employment checks and health and safety checks.
• The systems, processes and practice that helped to keep patients safe and safeguarded from abuse were insufficient. The system in place at the practice had not always ensured that all children who did not attend their appointment following referral to secondary care were appropriately monitored and followed up. Not all staff were aware of the practice safeguarding lead.
• The processes for managing information within the practice were not effective. Staff did not have the information they needed to deliver safe care and treatment due to a back log of administrative work.
• The process for monitoring patient’s health in relation to the use of medicines prior to prescribing was not always being followed.
• Not all significant events were reported or investigated and any learning that had been identified was not communicated effectively or embedded into practice.
• There was a lack of a systemic approach for ensuring patient safety alerts had been actioned.

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

• There was a lack of clinical oversight and structured information sharing.
• There was a lack of quality improvement activity.
• Information was not always shared effectively as it was not always available in a timely manner.
• Some performance data was significantly below local and national averages.

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

• The practice was unable to meet the needs of the practice population.
• Patients were unable to book either same day or pre-bookable appointments when they needed them. Staff were inconsistent with providing advice about alternatives services available to patients.
• Patients found it difficult to get through to the practice on the telephone and often queued to be attended to at the reception desk.
• The premises was not fit for purpose and the planned alterations had not taken place.
• The practice did not document informal comments and complaints and therefore trend analysis and learning could not be derived from these incidents.

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

• There was a lack of leadership within the practice at all levels.
• Not all staff felt valued, supported or safe in their roles.
• There were gaps in the practice’s governance systems and processes and the overall governance arrangements were ineffective.
• The practice had not implemented a clear and effective process for managing risks, issues and performance.
• We saw little evidence of systems and processes for learning and continuous improvement. Not all incidents were reported and investigated and any learning that had been identified was not communicated effectively or embedded.
• The practice did not document informal complaints and therefore trend analysis and learning could not be derived from these incidents.

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

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

• Patients did not always feel that they were treated with care and concern, involved in decisions about their care or listened to.
• Patients were not provided with information regarding alternative provision when staff were unable to offer appointments.
• The number of identified carers was below one percent.
• Confidentiality was difficult to maintain in the main reception area.

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 improve uptake of cervical screening.
• Continue to identify carers to enable this group of patients to access the care and support they need.

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