Archived: Gorse Hill Medical Centre

Gorse Hill (and Ayres Road) was initially inspected in January 2015 when it was rated requires improvement in Safe, Effective and Well Led. Improvements were required in medicines management, emergency equipment, recruitment protocols, staff training and governance arrangements.

The practice was re-inspected in December 2016 when it was found that the improvements had been implemented and it was rated Good overall.

We carried out this further announced comprehensive inspection to the practice on 21 January 2019. The inspection was part of our regulatory functions to check whether the provider was maintaining the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. Overall the practice is now rated as inadequate.

At this inspection the practice had not sustained the improvements demonstrated in 2016 and had further deteriorated.

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:

• Patients were at risk of harm because systems and processes were not sufficiently implemented to keep them safe.
• Arrangements for identifying, monitoring, recording and managing risks, and patient safety were not sufficiently managed.
• Incidents were not reported, documented, discussed and learned from.
• Patient consultations were not sufficiently documented to ensure that appropriate information was available to all clinicians reviewing patients.
• Patient safety alerts were not sufficiently communicated and acted upon.
• Recruitment checks were not consistently obtained and monitored.
• The practice could not demonstrate that all staff had the required safeguarding training at the appropriate levels.
• There were gaps in alert processes for safeguarding and no evidence that information about safeguarding incidents was communicated to all clinical staff.

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

• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement. There was no evidence of quality monitoring other than the Quality Outcomes Framework (QOF).
• Staff were not monitored sufficiently to ensure they had appropriate training and competency to carry out their roles.
• Local and national guidelines were not always adopted.
• Internal tasks, patient consultations and call and recall processes were not effective.

We rated the practice as Requires Improvement for caring because:

• Although comments to CQC from patients were positive about their interactions with staff we found that there had been complaints about staff attitude, specifically over the telephone.
• There was a lack of privacy evident at reception and the premises were not compliant with the Disability Discrimination Act.

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

• It did not take account of patient’s needs and preferences in a consistent manner.
• It did not organise and deliver services according to the needs of all patients.

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

• Leaders were not performing tasks intrinsic to their role and did not have appropriate knowledge of the requirements of the Health and Social Care Act.
• One of the sessional GPs did not consider themselves employees of the practice and there was no evidence of a whole team approach.
• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of formal communication and learning between all staff.
• Recruitment checks and personnel information was not sufficiently maintained in accordance with requirements.
• The practice could not demonstrate formal governance systems in place.
• There was no evidence of a consistent processes around dissemination of information, communication, patient safety, prescription management, safety protocols and risk management.
• The practice leaders were not aware of the potential issues within the practice.

The issues above affected all population groups so we rated all population groups as inadequate.

The areas where the provider must make improvements are as follows:

• Ensure that leaders can properly perform tasks that are intrinsic to their role
• Ensure that all patients are treated with dignity and respect
• Ensure care and treatment is provided in a safe way to patients
• Ensure patients are protected from abuse and improper treatment
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure specified information is available regarding each person employed and any such action as is necessary and proportionate is taken when any member of staff is no longer fit to carry out their duties

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

I am placing this service in special measures. 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.

Special measures will give people who use the service the reassurance that the care they get should improve.

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.