Archived: Iwade Health Centre

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced responsive comprehensive inspection at Iwade Health Centre on 6 June 2017. The overall rating for the practice was inadequate. The full comprehensive report on the 6 June 2017 inspection can be found by selecting the ‘all reports’ link for Iwade Health Centre on our website at www.cqc.org.uk.

During the announced responsive comprehensive inspection on 6 June 2017 we identified risk of harm to patients due to insufficient staffing numbers, a lack of effective governance processes and systems to identify, assess and monitor risk. This was a breach of legal requirements and the practice was rated inadequate overall. The practice was rated inadequate for providing safe, effective and well-led services, requires improvement for providing responsive services and good for providing caring services.

As a result of the inspection on 6 June 2017 the Care Quality Commission imposed urgent conditions on the registration of the service provider under Section 31 of the Health and Social Care Act 2008, in respect of all regulated activities for which they are registered. This urgent action was taken as we believe that a patient will or may be exposed to the risk of harm if we did not do so. The conditions were imposed on 14 June 2017 and included:

Condition 1: The registered person must not register any new patients at Iwade Health Centre without the written permission of the Care Quality Commission unless those patients are residents of the care and nursing homes attached to Iwade Health Centre or are newly born babies, newly fostered or adopted children of patients already registered at Iwade Health Centre.

Condition 2: The registered person must clear the existing backlogs of repeat prescription requests, medication reviews and Docman correspondence by 27 June 2017.

Condition 3: The registered person must implement a sustainable system to ensure future repeat prescription requests, medication reviews and Docman correspondence are reviewed and actioned without delay, to ensure patients are protected from risk of harm, at Iwade Health Centre.

Condition 4: The registered provider must undertake an urgent review of patient demand to determine the correct level of service provision and resource. This includes all appointment types requested by patients and the reasons for attendance. The review must also include a comprehensive outline of the required levels and numbers of the resource deployed to meet patient needs at all times. The initial review must be undertaken in conjunction with Swale Clinical Commissioning Group, documented and presented in a formal report to CQC by 24 July 2017.

Condition 5: The registered provider must ensure adequate capability, resource and capacity of all staffing groups in order to deliver a safe service. This includes providing adequate clinical staffing and appointments at Iwade Health Centre at all times to protect the health and welfare of patients.

Condition 6: Effective and sustainable clinical governance systems and processes to ensure that all patients are able to access timely, appropriate and safe care must be implemented by 24 July 2017 at Iwade Health Centre. The systems and processes implemented must protect patient safety and enable compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This inspection was an announced focused inspection undertaken on 1 August 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations identified, which resulted in urgent conditions being imposed to the providers’ registration, following our previous inspection on 6 June 2017. This report covers our findings in relation to the imposed conditions of registration and will not result in reviewing the overall rating or the ratings of any individual key question or population group.

Our key findings at this inspection, 1 August 2017, were as follows:

We found that none of the urgent conditions imposed on 14 June 2017 had been met.

• We found that condition one of the urgent conditions imposed on your registration had not been met. The registered manager carried out a search of patients registered at the practice since 14 June 2017 and provided documentation which showed that the practice had registered 42 new patients who did not meet the exception criteria.

• We found condition two of the urgent conditions imposed on your registration had not been met. Although there were no urgent repeat prescriptions awaiting action and the backlog of Docman correspondence seen did not pre-date 27 June 2017, medication reviews had not been conducted.

• We found condition three of the urgent conditions imposed had not been met. We saw that there were 36 blood results in a Docman shared inbox from 28 July 2017 to 01 August 2017 which had not been clinically reviewed and had not had any action taken. We reviewed a random sample of two blood results and found patients care had been placed at risk.

• We found condition four of the urgent conditions imposed on your registration had not been met. The registered manager confirmed that the required review of patient demand to determine the correct level of service provision and resource and the resulting report had not been produced.

• We found condition five of the urgent conditions imposed on your registration had not been met. The urgent review of patient demand to determine the correct level of resource and capacity of staffing to deliver a safe service had not been carried out. The expected GP (to cover the lead locum on annual leave) did not attend the surgery on 31 July 2017. Patient appointments were cancelled and rescheduled for the following day. A patient told us that her child’s appointment to see the GP was re-scheduled which resulted in her taking her child to the walk-in service. There were no permanent clinical staff at the practice except the healthcare assistant and the long term locum advanced nurse practitioner left the practice on 31 July 2017.

• We found condition six of the urgent conditions imposed on your registration had not been met. The provider was unable to demonstrate any systems had been employed to address and mitigate the risks to patients and had failed to share the urgent conditions imposed on the providers’ registration with Malling Health (UK) Limited staff and ensure they were adhered to.

As a result of this we sent a Letter of Intention to take urgent action under Section 31 of the Health and Social Care Act 2008 (‘the Act’), which included the power to impose, vary or remove conditions on the providers’ (Malling Health (UK) Ltd) registration. The provider negotiated a termination of contract with Swale clinical commissioning group for 31 August 2017. As a result we removed conditions two to six of those imposed on 14 June 2017 and imposed five further conditions on the registration of the service provider. There are therefore six urgent conditions imposed on the provider’s registration.

Condition 1 of those initially imposed being:

The registered person must not register any new patients at Iwade Health Centre without the written permission of the Care Quality Commission unless those patients are residents of the care and nursing homes attached to Iwade Health Centre or are newly born babies, newly fostered or adopted children of patients already registered at Iwade Health Centre,

and five newly imposed conditions taking account of the current situation at the practice.

Condition 1: The registered provider must work with the appointed incoming provider from the time the notice is served, for the duration of the contract with NHS Swale CCG until it terminates, to ensure patient care is maintained during the period of transition.

Condition 2: The registered provider must clear the backlog of medicine reviews and work with the appointed incoming provider to introduce a sustainable process to ensure this does not reoccur by 25 August 2017.

Condition 3: The registered provider must clear the backlog of prescriptions and work with the appointed incoming provider to introduce a sustainable process to ensure this does not reoccur by 25 August 2017.

Condition 4: The registered provider must clear the backlog of Docman correspondence and work with the appointed incoming provider to introduce a sustainable process to ensure this does not reoccur by 25 August 2017.

Condition 5: The registered person must provide the Care Quality Commission with a schedule of GP and clinical cover delivered by Malling Health (UK) Limited at Iwade Health Centre until the end of your contract with NHS Swale Clinical Commissioning Group by 2pm on 11 August 2017.

We have taken this urgent action as we believe a patient will or may be exposed to the risk of harm if we do not do so.

These conditions are imposed at the following location:

Iwade Health Centre, 1 Monins Road, Iwade, Sittingbourne, Kent ME9 8TY.

The provider Malling Health (UK) Ltd made an application to the Care Quality Commission to vary their conditions of registration by removing the location Iwade Health Centre from all the regulated activities they are registered to provide. The notice of decision to vary the conditions of registration to remove the location Iwade Health Centre was served on the provider on 1 September 2017. Malling Health (UK) Ltd is no longer the provider of regulated activates at Iwade Health Centre.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Iwade Health Centre on 6 June 2017. Overall the practice is rated as inadequate and urgent conditions have been placed on the providers registration which include: the restriction of new patients being registered; an urgent review of patient demand to determine the correct level of service provision and resource; the implementation of a sustainable system to ensure repeat prescription requests, medication reviews and correspondence are reviewed and actioned without delay and ensuring capable and sufficient staffing at the practice to deliver a safe service.

Our key findings across all the areas we inspected were as follows:

• The approach to investigating and reviewing significant events was insufficient. There was no evidence of learning from events or action taken to improve safety.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was no system for ensuring patient safety information was appropriately shared and acted upon.
• The practice were not able to provide documents or a training schedule to show who had received training. This included basic life support, safeguarding children and vulnerable adults relevant to their role and competence based training.
• The practice did not have a system to ensure staff who acted as chaperones were trained for the role or had received a Disclosure and Barring Service (DBS) check.
• An annual infection prevention control audit had been completed. However there were no records to show that action had been taken to address improvements identified as a result
• There were insufficient systems to ensure the safe prescribing and management of medicines, which included the review of high risk medicines and prescription pads were not monitored throughout the practice.
• Appropriate recruitment checks had not been undertaken prior to staff being employed
• Risk assessments regarding health and safety, fire safety COSHH and legionella had not been carried out or had not been actioned.
• The practice had achieved 96% of the total number of QOF points available.
• Although some single cycle audits had been carried out, we saw no evidence that these were informing and improving patient outcomes.
• Basic care and treatment requirements were not met. For example, there was an insufficient system to review patients regarding their medicine.
• The information needed to plan and deliver care and treatment was not available to relevant staff in a timely and accessible way.
• Multi-disciplinary meetings were not taking place.
• The majority of patients who responded to the national GP patient survey (2016) said they were treated with compassion, dignity and respect. However, patients spoken with reported a lack of continuity in their care due to the use of different locum GPs and nurses.
• There was no system to offer support to patients who identified themselves as carers.
• Information about how to complain was available to patients; however there was no evidence of learning being shared to mitigate further risk.
• Urgent appointments were usually available on the day they were requested.
• There was no clear division between the local and the corporate leadership structure and staff told us they were unsure where responsibility for governance lay.
• The most recent patient participation group meeting minutes were from 2015.

The areas where the provider must make improvements are:

• Ensure that sufficient numbers of suitably qualified, competent, skilled and experienced clinical staff members are deployed.

• Ensure systems and process to assess, monitor, manage and mitigate risks to the health and safety of patients who use services are in place.

• Introduce effective systems or processes to identify, report, record and act on and significant events, incidents and near misses.
• Ensure staff have the qualifications, competence, skills and experience to provide safe care and treatment, including safeguarding adults and children at the appropriate level and basic life support training.
• Ensure the proper and safe management of medicines.
• Establish and operate effective recruitment procedures to ensure that fit and proper persons are employed.
• Establish an appropriate system to ensure that the information needed to plan and deliver care and treatment is made available to relevant staff in a timely and accessible way.
• Ensure that people employed by the service receive training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
• Introduce effective systems to assess, monitor and improve the quality and safety of the services provided.

The areas where the provider should make improvement are:

• Review the recommendations made in the fire risk assessment are actioned and that fire evacuation procedures are rehearsed.
• Review the process for offering support to patients identified as carers.
• Review the process to alert the GP that a home visit request has been received.
• Improve the accessibility of the service.
• Review and update procedures and guidance.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice