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Inspection Summary


Overall summary & rating

Good

Updated 20 August 2018

This service is rated as Good overall. (Previous inspection August and September 2017 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced focused inspection at Lincolnshire Community Health Services NHS Trust (LCHS) GP out-of-hours service on 10 July 2018. This inspection was carried out to follow up on a breach of regulation in relation to safe care and treatment found at our previous focused inspection in August and September 2017. At that inspection the key question of safe was rated as requires improvement and therefore this inspection focused on the key question of safe.

At this inspection we found:

  • There was a process in place to ensure blank prescriptions were tracked throughout the service.

  • Patient Group Directions ensured that the prescriber evaluated the risks associated with high risk medicines which were to be left in a patient’s home.

  • The provider now had a system in place to ensure that medicines were dispensed safely and in the appropriate packaging.

  • Staffing at the Lincoln primary care centre had been reviewed to ensure that staff could observe patients in the waiting room at all times to ensure they were aware of deteriorating patients.

  • The provider was progressing the implementation of a medical workforce model to ensure staffing levels across all primary care centres were at the required minimum safe staffing level. Recruitment was still ongoing.

  • The risk register held clear information on the risk and impact or mitigating actions were recorded.

The areas where the provider should make improvements are:

  • Ensure that the planned signage improvements are implemented at Lincoln primary care centre.
  • Continue with the programme of recruitment to ensure staffing levels are appropriate and sustainable.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 August 2018

At our previous comprehensive inspection in August and September 2017, we rated the service as requires improvement for providing safe services. This was because;

  • The provider had not ensured that a process was in place to ensure blank prescriptions were tracked throughout the Lincoln primary care centre.
  • The provider had not ensured that PGDs in relation to some medicines ensured that the prescriber evaluated high risk medicines to be left in the patient’s home address or other setting and to handle it in accordance with that risk.
  • The provider had not ensured that some medicines were dispensed to patients at the Lincoln primary care centre in the appropriate packaging to ensure details of expiry dates, dosage and other information was provided to patients.
  • The provider had not ensured that adequate staffing levels were in place at the Lincoln primary care centre to ensure that staff based on the reception desk could observe patients in the waiting room at all times to ensure they were aware of worsening patients.
  • The provider had not ensured that medicines were dispensed safely to patients at the Lincoln primary care centre.
  • The provider had not ensured that staffing levels across all primary care centres were at the required minimum safe staffing level at all times as determined by the provider.

When we carried out this focussed inspection on 10 July 2018 we found improvements had been made.

We rated the service as good for providing safe services.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

At our inspection in August and September 2017 we found that the provider did not ensure that adequate staffing levels were in place at the Lincoln primary care centre to ensure that staff based on the reception desk could observe patients in the waiting room at all times to ensure they were aware of worsening patients.

At this inspection we were told that since May 2018 a clinician, employed by the provider had been working alongside the receptionist at the Lincoln primary care centre, signposting patients appropriately to either urgent care or A&E and also monitoring the waiting area. We were told that a new reception and waiting area within the urgent care centre had been developed in order to move away from the current arrangement of a shared reception with the A&E department. We visited the primary care centre and saw the new facilities and were told once this was completed there would be a separate urgent care entrance and patients presenting there would be streamed by the clinical navigator working alongside the receptionist. We saw that there were mirrors positioned to enable staff at the reception desk to monitor all patients in this waiting area. We were told that the reception desk would always be staffed if there were patients in the waiting area.


Also at our previous inspection we found that the provider had not ensured that staffing levels across all primary care centres were at the required minimum safe staffing level at all times but saw evidence of a proposed medical staffing model which at that time had not yet been implemented.

At this inspection we were told that the provider was still progressing towards a more sustainable workforce by employing GPs rather than using locums. The employed staff would work across urgent care which included the out of hours service. An additional four GPs had been recruited since our last inspection and all GP clinical lead positions had been filled. As part of the sustainable model, the provider had also increased the number of Advanced Clinical Practitioners and trainee Advanced Clinical Practitioners. Recruitment was still ongoing with some clinical positions still being advertised, others awaiting interview and some due to take up post.

At our previous inspection we found that the arrangements in place for identifying, recording and managing risks, issues and implementing mitigating actions required further improvement as the risk register did not provide clear information on the risk or the actual impact or mitigating actions.

At this inspection we spoke with the Quality Assurance Manager for urgent care and out of hours provision. This was a new position and they had been in post since October 2017. They told us part of their role was to monitor the risk register. We also looked at the updated risk management strategy and also relevant risk registers. One member of staff we spoke with described a risk which had been identified and how it was being addressed through the risk management system which was in line with the risk management strategy. We saw that the risk register included details of impact and mitigating actions.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

At our inspection in August and September 2017 we found that the provider had not ensured that a process was in place to ensure blank prescriptions were tracked throughout the Lincoln primary care centre.

At this inspection we were told that the process had been reviewed and a standard operating procedure introduced in order to monitor the movement of prescriptions through the service and that locks had been installed on all printers which held prescriptions. We found that there was now an effective system in place to monitor the movement of blank prescriptions through the service, including prescriptions that were held in vehicles. Blank prescription forms were logged out from Beech House to each location and when we visited the Lincoln primary care centre we saw that blank prescriptions were held securely and there was a log in each clinical room which recorded the serial numbers of prescription forms held in the printer in that room. We were told the system was in the process of being updated to use biometric technology for increased security but this was not yet operational.

The provider had also made improvements to an existing medicines audit to provide assurance for the safe and secure handling of medicines and blank prescriptions. We saw that this revised audit had been completed in quarter four of 2017/18 and the first quarter of 2018/19.

At our inspection In August and September 2017 we found that the provider did not ensure that some medicines were dispensed to patients at the Lincoln primary care centre in the appropriate packaging to ensure details of expiry dates, dosage and other information were provided to patients. At the time of that inspection the provider immediately withdrew supplies of the affected medicines and replaced them with packets containing the full course and the necessary information.

At this inspection we spoke with the Medicines Management Lead who told us that they had worked with their medicines supplier to ensure that boxes of medicines were not split and only full boxes supplied. There was now a process in place to audit this on a quarterly basis. They had also worked with their pharmacy contract holder in respect of labelling of medicines to ensure that the labels were secure and did not obscure expiry dates. This aspect was also included in the quarterly medicines audit.

At our inspection In August and September 2017 we found that the provider did not ensure that Patient Group Directions (PGDs) in relation to some medicines ensured that the prescriber evaluated high risk medicines to be left in the patient’s home address or other setting and to handle it in accordance with the risk.

At this inspection we found that this risk had been addressed. We were told that relevant PGDs had been reviewed and the wording changed to address this risk and the PGDs reissued. Additionally, training in this area had been re-introduced to the mandatory training programme and we saw the lesson plan for Medicine Management and PGD use in relation to this.

Effective

Good

Updated 20 August 2018

Caring

Good

Updated 20 August 2018

Responsive

Good

Updated 20 August 2018

Well-led

Good

Updated 20 August 2018

Other CQC inspections of services

Community & mental health inspection reports for Beech House can be found at Lincolnshire Community Health Services NHS Trust.