Archived: Highley Medical Centre

We carried out a comprehensive announced inspection at Highley Medical Centre on 15 November 2021. Overall, the practice is rated as inadequate. It is rated as:

• Inadequate for providing safe care and treatment
• Requires improvement for providing effective care
• Good for caring
• Requires improvement for providing responsive care
• Inadequate for well-led

Following our previous inspection on 17 May 2016, under a previous registered provider, the practice was rated Good overall and good for all five key questions. The archived reports for previous inspections can be found by selecting the ‘all reports’ link for Highley Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection following changes in registration and legal entity and concerns we had received in relation to care and treatment and good governance.

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 and on site and a staff questionnaire
• 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 rated the practice as inadequate for providing safe care and treatment. This is because:

• The practice was unable to provide assurances that all staff had completed safeguarding and other training in safe working practices.
• The practice had not always acted effectively on potential safeguarding information.
• Recruitment checks were not carried out in accordance with regulations.
• The systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be at risk were not effective.
• Not all staff had received a formal, structured induction appropriate to their role.
• Patients prescribed high risk medicines had not always received the required blood test monitoring in line with best practice guidance and number of patients were overdue a medicine review.
• Systems for recording significant events did not always identify the learning, actions or trends and there were missed opportunities to raise and analyse significant events.
• Not all of the suggested emergency medicines or equipment was available in the event of a medical emergency. No risk assessment had been undertaken for not stocking the suggested emergency medicines or equipment.
• The system to review and act on patient safety alerts was not effective.
• Evidence that staff vaccination and immunity for potential health care acquired infections was not recorded or risk assessed for all staff files.

We rated the practice as requires improvement for providing an effective service. This was because:

• Patients with long-term conditions were not always offered a structured annual review to check their health and medicines needs were being met.
• Clinicians had not always worked in line with national guidance or acted on patient safety alerts.
• Clinicians had not always informed patients about abnormal results and referrals to secondary care which may have impacted on their health.
• There was no overarching system in place to monitor compliance with staff training therefore the practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
• The practice did not have formalised systems in place to ensure staff worked within the limits of their competency or to review their performance.
• Quality audits had been completed however, it was not always clear if the actions identified had been implemented and if so, what the impact had been.

We rated the practice as good for caring. This is because:

• Staff treated patients with kindness, respect and compassion.
• There were systems in place to support carers.

We rated the practice as requires improvement for responsive because:

• The practice had not always been responsive to the needs of their patients.
• A number of complaints had been raised by patients in relation to access to appointments, particularly face-to-face appointments.
• The practice could not always demonstrate learning from complaints and opportunities to record complaints had been missed.

We rated the practice as inadequate for providing a well-led service. This is because:

• Structures, processes and systems to support good governance and management were not effective.
• Leaders could not demonstrate that they had the capacity and skills to address the challenges within the practice.
• Policies to support the governance and safe running of the practice were not being adhered to, for example the recruitment policy.
• Effective processes for managing risks were not in place.
• The practice had not developed a succession plan for the protection of the practice, the patients and staff.
• There was no overarching system in place to identify trends in complaints or significant events or to review the effectiveness of any possible changes made within the practice.

We found five breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients
• Ensure all premises and equipment used by the service provider is fit for use
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

• Complete the identified actions in the external health and safety report.
• Develop a quality improvement programme with a formalised improvement plan.

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 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