Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Colby Medical Centre on 29 January 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 29 January 2016 inspection can be found by selecting the ‘all reports’ link for Colby Medical Centre on our website at www.cqc.org.uk.

At our previous inspection in January 2016 we rated the practice as ‘requires improvement’ in providing safe, effective and well led services. The practice was therefore rated as ‘requires improvement’ overall. We issued two requirement notices to the provider relating to recruitment and staffing levels. The provider sent us an action plan and also assurances that they would mitigate any risks identified.

This inspection visit was carried out on 28 September 2017 to check that the provider had met their plan to meet the legal requirements. The findings of this inspection were that whilst the provider had taken some action to meet the legal requirement notices, other issues highlighted in the previous report had not been addressed and there were other areas of concern identified. As a result the practice has been rated as inadequate.

Our key findings were as follows:

• Some improvements had been made to the recruitment process to ensure patients were treated and cared for by appropriately skilled and competent staff.

• Some improvements had been made to support provided to staff through the appraisal system. However further improvement was needed to ensure clinical support arrangements for the Advanced Nurse Practitioner and Nurse Clinician were formalised.

• Some improvements had been made to the way significant events were managed but we found similar issues to those identified in the last inspection. For example, a periodic review of events to determine trends was not in place. We saw two examples where the provider had failed to recognise an event as a significant event and therefore they had not taken action to investigate the matter or to put systems in place to prevent a reoccurrence.

• Medical equipment had been tested and calibrated since the last inspection.

• There were gaps in medicines management systems. For example, a recent medication update had not been actioned. There was no system to monitor uncollected prescriptions to ensure vulnerable patients receive their medication in a timely manner. The monitoring system for emergency medicine expiry dates required improvement.

• Staff understood their responsibilities in relation to safeguarding. However, the systems in place did not capture relevant information on patient records to alert clinicians that patients were subject to any part of the child protection process.

• Clinicians were not accessing the most recent guidance to support the appropriate and safe treatment of patients.

• We found examples where the practice had not followed up instructions in correspondence from hospitals and therefore actions had not been taken to provide necessary treatment and monitoring of patients.

• At the previous inspection and at this inspection there was limited evidence that the clinical audits undertaken demonstrated quality improvement.

• The practice had good facilities, including disabled access. It was well equipped to treat patients and meet their needs. Infection control practices were in place and there were regular checks on the environment and on equipment used.

• Access to the service was monitored to ensure it met the needs of patients.

• There was a system in place to manage complaints.

• Staff felt supported. They had access to training and development opportunities appropriate to their roles.

• Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.

The provider needs to make improvements.

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patient’s particular regard to the monitoring of emergency drugs, patients on high risk drugs and the communication and management of correspondence.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. To ensure patients receive safe and appropriate care.

In addition the provider should:

• Review the safeguarding system to ensure patient records alert staff if the patient is subject to any part of child protection processes.

• Review the use of care planning to support the most vulnerable patients within the practice.

• Continue to monitor the staff recruitment and retention process to ensure appropriate checks are carried out to promote the safety and wellbeing of patients.

• Introduce a system to monitor uncollected prescriptions to ensure vulnerable patients receive their medication in a timely manner.

• Review how clinicians accessed clinical guidance to ensure it was the most recent to support the appropriate and safe treatment of patients.

We are now taking further action in relation to this provider and will report on this when it is completed.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 varying the terms of their registration within six months if they do not improve.

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 Colby Medical Centre Ltd on the 29 January 2016. Overall the practice is rated as requires improvement.

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

• Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood their responsibilities to raise concerns, however not all incidents discussed with the inspection team had been reported. The practice did not keep a log of all safety incidents or carry out an analysis of the significant events on an annual basis.

• There were arrangements in place to safeguard adults and children, but staff had not completed recent safeguarding training.

• Arrangements were in place to keep medicines safe.

• Staffing levels were inadequate at the time of our inspection due to staff sickness and a number of vacancies that had recently arisen.
• Urgent appointments were usually available on the day they were requested.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff received training appropriate to their roles and any further training needs had been identified and planned. Annual appraisals for all staff had not been completed.

• Patients care and treatments were monitored, but robust clinical audits were not taking place.

• Information about services and how to complain was readily available in document form for patients. Clear complaint procedures were in place, monitored and reviewed.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The practice was clean and well maintained.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• There was a clear leadership structure and staff felt supported by management despite there being a number of staffing issues over the previous year. The practice proactively sought feedback from staff, which it acted on.

• The practice had proactively sought feedback from patients and had an active patient participation group.
• Feedback from patients on the day of the inspection about their care was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

The areas where the provider must make improvements are:

• The provider must ensure recruitment arrangements include all necessary employment checks for all staff.

• Arrangements for ensuring all staff, including the clinicians, received appropriate support, supervision and appraisal must be reviewed.

The areas where the provider should make improvements are:

• All staff should undertake vulnerable adult safeguarding training and the practice lead for safeguarding should complete Mental Capacity Act 2005 training.

• All clinicians should ensure that at risk children who fail to attend hospital appointments are followed up by the practice.

• Records to show that all equipment has been maintained, tested, serviced and calibrated should be available for inspection.

• Infection control training should be completed for the practice infection control lead.

• The provider should monitor the quality of service patients receive by having a robust system of clinical audits in place. The provider should consider how the results of these can be used to monitor and improve patients outcomes.

• Regular meetings should take place with the local health visiting service to review and update information held about children and vulnerable families with safeguarding risks.

• The staffing arrangements should be reviewed to ensure that patients can access a GP on a daily basis.

• Minutes should be taken for staff meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating September 2017 - Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

We carried out an announced comprehensive inspection at Colby Medical Centre on 12 September 2018 as a follow-up inspection on breaches of regulations.

This was the third follow-up comprehensive inspection completed at the service.

At an inspection in January 2016 we rated the practice as ‘requires improvement’ in providing safe, effective and well led services. The practice was therefore rated as ‘requires improvement’ overall. We issued two requirement notices to the provider relating to recruitment and staffing levels. The provider sent us an action plan and assurances that they would mitigate any risks identified.

We carried out a follow-up inspection to that inspection out on 28 September 2017 to check whether that the provider had met their plan to meet the legal requirements, the report was published in March 2018. The findings were that whilst the provider had taken some action to meet the legal requirement notices, other issues highlighted in the previous 2016 report had not been addressed and there were other areas of concern identified. As a result, the practice was rated as inadequate in the safe and well-led domains and requires improvement in the effective domain. This meant the practice was rated inadequate overall and placed into special measures. The provider sent us an action plan and assurances that they would mitigate the risks identified.

We carried out a comprehensive follow-up inspection on 12 September 2018 to check that the provider had met their plan to meet the legal requirements and review whether there were sufficient improvements to take the practice out of special measures.

The findings of this inspection were sufficient improvements to take the practice out of special measures and the practice is now rated as Good overall.

• The practice had improved systems to manage risk.
• Improvements had been made to ensure clinical support arrangements were recorded, however these records could be documented more formally.
• Improvements had been to the management of significant events and were recorded so that trends could be identified. We saw that the provider recognised and acted on significant events. When incidents did happen, the practice learned from them and improved their processes.
• Medicines management had improved. Recent medicines alerts had been actioned and there was a clear process for managing uncollected prescriptions which was understood by staff. All patients on high risk medicines had been reviewed in a timely manner and emergency medicines expiry dates were monitored.
• Safeguarding systems had been improved to ensure relevant information was placed on patients records to alert clinicians when a child was subject to any part of the child protection process.
• Processes were now in place to ensure clinicians had ready access to the most up to date guidance to support the appropriate and safe treatment of patients. Adherence to best practice was audited and action taken to review this with internal staff.
• Processes for dealing with correspondence had been improved and systems were in place to ensure all instructions were actioned by the appropriate clinician or administrative staff. The processes were understood by staff and the effectiveness of the changes in ensuring patients received the necessary treatment was monitored.
• A programme of clinical audits had been introduced to review the effectiveness of care and identify possible areas for improvement.
• The system for dealing with complaints needed to improve.
• We found that staff felt supported at the practice and were provided with training opportunities to develop their skills.
• There were regular clinical and team meetings and processes to improve communication in the practice had been developed.
• Patients said they were treated with dignity and trusted the staff.
• The provider had a good relationship with the wider multidisciplinary team members.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided and ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to carrying on of the regulated activity. Ensure any complaint received is investigated and appropriate action is taken in response to any failure identified by the complaint or investigation.

The areas where the provider should make improvements are:

• Consider how best to educate patients and prompt staff about signs, symptoms and treatment for sepsis.
• Ensure that the investigation of incidents is based on the policy and guidance relating to the incident and appropriate remedial action always taken.
• Ensure there are clear protocols for managing the performance of locum or temporary staff which are consistently followed.
• Review the competencies needed by staff to ensure the improvements made are sustained and built on.
• Complete a premises risk assessment specific to their staff and patients.
• Review access and availability to emergency equipment and oxygen.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice