Archived: Albion Place Medical Practice

We carried out an announced inspection at Albion Place Medical Practice on 6 October 2021. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective – Inadequate

Caring - Good

Responsive – Requires improvement

Well-led - Inadequate

Following our previous focused inspection carried out between 30 March and 8 April 2021, the practice was not rated. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Albion Place Medical 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 concerns raised regarding the service and to rate the location:

• We inspected all five key questions.
• We reviewed ‘shoulds’ from our previous inspection including staffing levels, systems for monitoring patients prescribed high risk medicines and how complaints were managed.

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 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 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 Inadequate overall

We found that:

• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The practice had a high turnover of staff and was still carrying vacancies for clinical and non-clinical staff.
• Systems for managing risks were not operating how leaders in the service intended which meant patients did not always receive effective care and treatment that met their needs.
• There was a large backlog of incoming correspondence which the practice had not taken sufficient action to address.
• Pathology results were not always reviewed within an appropriate timescale.
• Learning from incidents and complaints were not always identified or shared to drive improvement.
• Staff told us that they dealt with patients with kindness and respect.
• Leaders and staff in the service had a strong desire to provide high quality patient care but this was not supported by a credible strategy.

We found three breaches of regulations. The provider must:

• Ensure 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 and treatment.

In addition, the provider should:

• Review and increase uptake of national programmes including childhood immunisations and cervical cancer screening.
• Continue to review and improve patient satisfaction and access to care.

On 20 October 2021, Albion Place Medical Practice was issued with an urgent notice to impose conditions upon their registration as a service provider in respect of regulated activities, under Section 31 of the Health and Social Care Act 2008. This notice of decision of urgent conditions was given because we believed that patients would or may have been exposed to the risk of harm if we did not take this action.

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