Archived: Shadwell Medical Centre

Updated 1 September 2021

Shadwell Medical Centre is located on the outskirts of Leeds at:

137 Shadwell Lane

Leeds

West Yorkshire

LS17 8AE

The location was visited as part of this inspection activity.

The practice is situated within Leeds Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of approximately 4,640. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices, known as a Primary Care Network (PCN).

The provider of Shadwell Medical Centre consists of a partnership between the lead GP and a non-medical partner (who does not work at the practice). They are registered with the Care Quality Commission (CQC) to deliver the Regulated Activities: diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

Following our inspection on 18 June 2021, we suspended the provider’s CQC registration to deliver those regulated activities, having identified significant concerns which put patients’ safety at risk. The suspension took effect from 23 June 2021 and will remain in place until 22 September 2021. Leeds CCG have arranged for another GP practice to provide services in the interim period for patients registered at Shadwell Medical Centre.

Information published by Public Health England shows that deprivation within the practice population group is in the highest decile (10 of 10). The higher the decile, the least deprived the practice population is.

According to the latest available published data, the ethnic make-up of the practice area is approximately 80% white, 14% Asian, 2% black, 2% mixed and 2% other. The gender and age distribution of the practice population shows there are similar numbers of male and female patients across all age groups. There are a higher number of patients aged 40 to 90 years, and lower numbers of patients aged 0 to 30 years, compared to local and national averages. The life expectancy for male patients is 82 years (compared to 79 years nationally) and 86 years for female patients (compared to 83 years nationally).

At the time of our inspection, the clinical team consisted of a full-time GP (the lead GP) and two part-time locum GPs. There is a part-time employed nurse, a part-time locum nurse and a part-time employed advanced nurse practitioner. The clinical team are supported by a primary care network (PCN) pharmacist and phlebotomist, along with a range of other PCN staff. There is a team of reception and administration staff, including a secretary, all of whom work part-time hours. The practice manager had previously submitted their resignation but was currently working at the practice during the period of suspension.

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 are telephone consultations. The practice has some face-to-face appointments with a locum GP or nurse.

Extended access is provided locally by PCN staff, where late evening and weekend appointments are available. Out of hours services are provided by Local Care Direct. The practice is also supported by a home visiting service provided by the local confederation, who visit unwell housebound patients.

Updated 1 September 2021

We carried out an announced focused inspection of Shadwell Medical Centre, 137 Shadwell Lane, Leeds, West Yorkshire LS17 8AE, which commenced on 7 June 2021. During that inspection, we undertook an unannounced site visit on 18 June 2021.

Overall, the practice is rated as Inadequate.

We have rated the practice as follows:

Safe - Inadequate

Effective - Inadequate

Caring - Not rated

Responsive - Inadequate

Well-led - Inadequate

We had undertaken a previous inspection in October 2020, as a result of concerns received. This inspection did not result in a rating. The last rated inspection was in April 2018 when the practice was rated as good overall, with some identified areas for improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shadwell Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We commenced this announced focused inspection on 7 June 2021 as a result of concerns we had received. However, during the inspection process we received further concerns regarding staffing levels and undertook an unannounced site visit on 18 June 2021.

This was a focused inspection responding to specific areas of concern, which resulted in not all areas within safe, effective, responsive and well-led being reviewed or reported upon. We did not review or report on caring. Therefore, we have carried forward the rating from the inspection undertaken in 2018, meaning that caring currently remains good.

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 either telephone or video calls.
• Completing clinical searches on the practice electronic patient records system.
• Reviewing patient records to identify issues and any clarify actions taken by the provider.
• Requesting evidence from the provider.
• Speaking to staff from external health care organisations.
• Undertaking an unannounced site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found during the inspection and on the site visit
• 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 inadequate for all population groups.

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

• Systems and processes relating to safety, including infection prevention and control and patient safety alerts, were not developed and implemented in a way that kept people safe.
• Risks assessments relating to the premises and staff were not always undertaken or identified actions addressed.
• The provider did not have clear safeguarding processes in place to keep patients safe. Not all staff were up-to-date with the appropriate level of safeguarding training for their role and safeguarding meetings were not held.
• There was little evidence of an effective system for managing patient referrals to other services. For example, safety-netting urgent two week wait referrals.
• There were a large number of outstanding tasks relating to patients to be actioned, such as medicine changes, dealing with abnormal pathology results and arranging for a patient to be seen by a doctor.
• There was no clear process for managing changes in medication and the review of patients on prescribed medication. Clinical record searches identified patients who had not received appropriate monitoring in line with guidance, such as those who were prescribed high-risk medicines.
• There was no clinical supervision, or auditing, of non-medical prescribers to ensure they were competent in their role and prescribing appropriately.
• Incident reporting and management processes were not effective. There was no evidence of identifying any actions and learning from incidents, or sharing information with staff.
• Patients’ paper records were not always kept secure and managed appropriately.
• Recruitment checks and processes were not undertaken in accordance with guidance and the practice policy. There was no clear induction system for new or temporary staff.
• There was not an effective approach to managing staff absence and busy periods in the practice.

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

• There was no clear system to ensure that clinicians were up-to-date with evidence-based practice.
• There was not an effective system in place for the recall and review of patients. Clinical record searches identified patients who had not been fully assessed or reviewed in line with guidance. For example, those patients who had a long-term condition or prescribed high-risk medicines.
• There was limited monitoring of the outcomes of pathology results, care and treatment. Clinical record searches identified patients who had possible missed diagnoses, which included diabetes and chronic kidney disease.
• There was an absence of care management plans in place for patients, particularly relating to those requiring palliative care or who were living with dementia.
• Cervical screening uptake was lower than local and national averages and there was little evidence of an effective practice recall system or enough nursing hours to cope with demand.
• There was little evidence of a programme of quality improvement in place, which included clinical audits, or sharing audits and outcomes with staff.
• The provider was unable to demonstrate that all non-clinical and clinical staff had the skills, knowledge and experience to carry out their roles. Some staff were asked to work outside their role or competency. Not all staff were not up-to-date with mandatory training. Staff did not receive annual appraisals or training and development assessments.
• There was little evidence of coordination of patient care with other services. There was a lack of clinical meetings within the practice or with other health and social care professionals.

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

• The provider could not demonstrate that care was consistently delivered and coordinated with other services for some population groups.
• There was an ineffective rota system to support the numbers and type of appointments available on a daily basis for patients to access. Patients complained of long waits for the practice telephone to be answered by a member of staff.
• There were no clear systems in place to manage patients with urgent needs. On some days there was no clinician working on site, should a patient need a face-to-face appointment or a baby require immunising. We saw evidence of delayed access to patient care and treatment.
• Feedback from patients about accessing the practice was negative.
• Complaints were not dealt with in line with the practice policy. There was no identified learning or sharing with staff.

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

• The provider could not demonstrate they had the capacity and skills to deliver high quality, sustainable care.
• There was a lack of leadership in the practice leading to a risk of patient harm. Staff reported that the lead GP was rarely visible in the practice.
• The overall governance arrangements were ineffective. There was no clear vision and strategy for the practice. There was little evidence of systems in place to ensure compliance with the requirements of the duty of candour.
• There was little evidence of continuous improvement and innovations, including any shared learning within the practice.
• There was no evidence of a succession plan or leadership and development programme in place for staff.
• There was a lack of awareness of a Freedom to Speak Up Guardian available for staff to access.
• Staff reported a culture of bullying, intimidation and a fear of the lead GP.

We found breaches of regulations. The areas the provider must improve are:

• Ensure that 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.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care.
• Ensure that persons employed in the provision of regulated activities received the appropriate support, training, professional development, supervision and appraisals necessary to enable them to carry out their duties.

Following our site visit on 18 June 2021, due to significant safety concerns and risk of harm to patients, we issued a notice of decision to urgently suspend the provider’s registration under Section 31 of the Health and Social Care Act 2008. The suspension took effect from 23 June 2021 and will remain in place until 22 September 2021.

The local Clinical Commissioning Group arranged for another GP practice to provide services for patients in the interim.

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

Updated 13 August 2021

Updated 13 August 2021

Updated 13 August 2021

Updated 13 August 2021

Updated 13 August 2021

Updated 13 August 2021