Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – requires improvement

Are services caring? – requires improvement

Are services responsive? – requires improvement

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – requires improvement

People with long-term conditions – requires improvement

Families, children and young people – requires improvement

Working age people (including those recently retired and students – requires improvement

People whose circumstances may make them vulnerable – requires improvement

People experiencing poor mental health (including people with dementia) – requires improvement.

We carried out an announced comprehensive inspection at Crossroads Medical Practice in September 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. On 7 July 2016 we carried out an announced comprehensive inspection to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings in September 2015. The full comprehensive reports on the September 2015 and July 2016 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

An inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 9 March 2017. Overall the practice was rated as inadequate as insufficient improvements had been made. We carried out an announced focussed inspection of Crossroads Medical Practice on 17 May 2017. This was to check compliance relating to the serious concerns found during the comprehensive inspection on 9 March 2017 which resulted in conditions being imposed on the registration and a notice of proposal to cancel the practice registration was served. We found at that inspection sufficient improvements had been made in relation to breaches of Regulation 12 (Safe care and Treatment) and Regulation 17 (Good Governance). We therefore withdrew the notice of proposal to cancel the service and the practice remained in special measures.

This inspection on 7 November 2017 carried out following the third period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

At this inspection we found:

• Significant improvements had been made since the inspection in March 2017.

• Patients were no longer at risk of harm because adequate systems were in place to keep patients safe including those for dealing with high risk medicines and patient safety alerts.

• Management of high risk medicine prescribing had improved and regular audits were completed to ensure effectiveness.

• The practice had regular monthly meetings with the health visitor to enable joint working, discussion and review of children at risk.

• The process for managing patient safety alerts was effective. We saw that searches had been completed and patients contacted where needed. We saw ongoing evidence of repeated searches to check that any new patients were captured if affected by an alert.

• The system to ensure employment checks were carried out was effective. The locum files were organised, structured and had documented evidence of all checks and training required.

• There was a process for disseminating NICE guidance. Clinical meetings included discussion of NICE guidance in the minutes that we viewed.

• The practice had a plan in place for clinical audit. We saw audits had been completed and were scheduled to have a second cycle. Non clinical audit was in place to evaluate and inform decisions on future staffing and improving patient outcomes.

• Data from the Quality and Outcomes Framework showed patient outcomes were in line with the average for the locality and compared to the national average. However, there had been a decrease in scores from 2015/16 compared with 2016/17. We saw evidence of work to look at ways this would be improved for the future, including recruitment and ensuring the correct skill mix.

• Some of the national patient satisfaction survey results from July 2017 that were below national and CCG averages results had decreased. However scores regarding nurse consultations had improved.

• The practice had reviewed the patient satisfaction survey and had an action plan for work to improve further.

• The practice had developed a triage system for patients which meant that any patient who felt they needed an appointment on the day would be passed to a nurse practitioner or GP who would contact the patient. The clinician would then book an appointment if required. Pre-bookable appointments were available for GPs. However this was one week in advance which was problematic for patients and reception staff when the GP told the patient they should re-book for two weeks time.

• Staff had the skills, knowledge and experience to deliver effective care and treatment although the practice had highlighted that they needed some further knowledge and staff to manage some long term conditions more effectively.

• Information about services and how to complain was available and easy to understand.

• Complaints had been acknowledged and responded to. We saw that learning from complaints was shared as part of the bi-monthly significant event meetings.

• The process for reporting, reviewing and investigating significant events was effective. We saw that there were no outstanding significant events for review and those that had been reported had been actioned, reviewed and lessons learned had been discussed. There were detailed minutes for staff who had been unable to attend the meetings.

The areas where the provider should make improvements are:

• Continue to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, ensuring there are systems in place in order to provide patient care in relation to the monitoring of patient’s health conditions.

• Review the procedure to ensure that fridge temperatures are checked and emergency equipment checks are completed in line with the practice protocol.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 focussed inspection of Crossroads Medical Practice on 17 May 2017. This was to check compliance relating to the serious concerns found during a comprehensive inspection on 9 March 2017 which resulted in conditions been imposed on the registration and a notice of proposal to cancel the practice registration was served. Other areas of non- compliance found during the inspection on 9 March 2017 will be checked by us for compliance at a later date.

The full comprehensive reports on the September 2015, July 2016 and March 2017 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

At this inspection in May 2017, we checked the progress the provider had made to meet the significant areas of concerns as outlined in the conditions imposed and the notice of proposal to cancel registration, for breaches of Regulation 12 (Safe care and Treatment) and Regulation 17 (Good Governance).

Our key findings were as follows:

• We found that all previous significant events that were waiting review had been discussed and reviewed in addition to new events that had been raised.

• The practice had completed reviews of each event and this included learning and actions taken.

• The protocol for managing safety alerts had been reviewed. We looked at the review completed in the practice of all alerts in 2016/17 and looked at searches completed in relation to the ones applicable in primary care.

• All staff had completed the required level of safeguarding training relevant to their role.

• We reviewed records of patients on high risk medicines. We found that the practice had an effective system in place for ongoing monitoring of high risk medicines.

• Shared care protocols (that outlined ways in which the responsibilities for managing the prescribing of a medicine could be shared between the specialist and the practice) were accessible to staff in a folder at reception and a link to these was also on the practice computer system to enable all clinicians’ instant access to them for reference.

• Safeguarding meeting dates had been set for each month of the coming year. One meeting had taken place and there was an agreement in place between the practice and health visitors to have monthly face to face children safeguarding meetings going forward.

• The practice had an effective system in place to ensure employment checks were carried out for all staff including locums.

• We reviewed evidence for disseminating NICE guidance. Clinical meetings had NICE guidance on the agenda and in the minutes that we viewed.

• The practice had a plan in place for clinical audit. At this inspection we viewed a number of audits that had commenced some of which were linked to NICE guidance. One in relation to patients on warfarin showed quality improvement.

• Pre-bookable appointments were available for GPs and nurse practitioners had been recruited and provided appointments and undertook triage of patients.

• Extended hours pre-bookable appointments were available four days per week.

• The practice had implemented a review of complaints similar to the significant events which looked at any learning or changes to practice and included reflection by the staff member involved when appropriate.

• We found that overall leadership had improved. Since the inspection in March 2017 the practice had a new staff structure in place. A new GP had commenced and taken on the role of clinical lead and two nurse practitioners were in post.

The other key lines of enquiry will be reassessed by us at another inspection when the provider has had sufficient time to meet the outstanding issues. At that time a new rating will be assessed for the provider.

The issues that the practice should address are:

• Continue to embed systems in place to improve safety for patients.

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 Crossroads Medical Practice in September 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. On 7 July 2016 we carried out an announced comprehensive inspection to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings in September 2015. The full comprehensive reports on the September 2015 and July 2016 inspections can be found by selecting the ‘all reports’ link for Crossroads Medical Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 9 March 2017. Overall the practice is rated as inadequate.

Our key findings were as follows:

• Patients were at risk of harm because inadequate systems were in place to keep patients safe including those for dealing with high risk medicines and patient safety alerts.

• There had been no improvement in the management of high risk drug prescribing.

• The system for safeguarding children had been strengthened and the practice had reviewed the clinical coding so they could identify those children at risk. However, there had been no consistent discussions to review these patients.

• The process for managing patient safety alerts was not effective. There was no evidence of searches being carried out to identify if the alerts were applicable and no evidence of action taken. We looked for five alerts that that had been issued related to primary care in 2016/17 and found one in the folder. The other four alerts had not been received.

• Some risks to patients who used services were assessed and identified actions had now been implemented. However, the practice did not have an effective system in place to ensure employment checks were carried out for all staff including locums.

• We found no evidence of a process for disseminating NICE guidance. Clinical meetings did not have NICE guidance on the agenda or in the minutes that we viewed.

• The practice had a plan in place for clinical audit. However this plan had not been adhered to and there was no evidence of quality improvement.

• Data from the Quality and Outcomes Framework showed patient outcomes were in line with the average for the locality and compared to the national average. However, we saw examples of patients not coded correctly for their diagnosis. This meant that these patients would not be included in the QOF for that area and patients would not be invited for any reviews that were necessary.

• Some of the national patient satisfaction survey results from July 2016 were below national and CCG averages results. For example

  • 72% of patients were satisfied with the surgery's opening hours CCG average of 78% and national average of 76%.

  • 43% of patients usually get to see or speak to their preferred GP CCG average of 61% and national average of 59%.

• The practice did not have enough appointments available on a daily basis. There were no pre-bookable appointments for GPs.

• Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Information about services and how to complain was available and easy to understand.

• Complaints had been acknowledged and responded to. However, we were still unable to see evidence of sharing the learning of complaints, or any discussion or analysis at meetings.

• The process of identifying patients at high risk of admission to hospital which had commenced in July 2016 was still not complete.

• The process for reporting significant events had improved but the system for reviewing and investigating was not effective as we saw 20 significant events that had been completed that were not reviewed, actioned or discussed.

Importantly, the provider must:

• Ensure patients receive safe care and treatment to include the proper and safe management of high risk medicines.

• Ensure that an accurate, complete and contemporaneous record is maintained for every patient to include a record of the care and treatment provided to them and of decisions taken in relation to the care and treatment provided

• Ensure that the risks to patient health, safety and welfare are assessed, monitored and managed, taking into account the most up to date evidence based guidance such as through the use of MHRA alerts.

• Ensure effective systems are in place to ensure that care and treatment is delivered to patients in a safe way by using the significant events, incidents, near misses and complaints to continually evaluate and improve.

• Ensure effective systems are in place that enables the provider to assess, monitor and improve the quality of the clinical care services provided. Assess whether clinicians have the up to date clinical information available to them and mitigating any such risks identified such as implementing a system of effective clinical audits.

• Ensure there is an effective and consistent system for employment checks to be carried out for all staff including locums.

• Ensure people working at the service receive the appropriate training to carry out their role.

• Use the feedback from the national GP survey to evaluate and improve services.

This service was placed in special measures in September 2015. Insufficient improvements have been made such that there remains a rating of inadequate for safe and well-led. Therefore we are taking 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. Conditions were imposed on 13 March 2017.

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 Crossroads Medical Practice on 7 July 2016. The purpose of this inspection was to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings at our inspection in September 2015 when we found the practice to be inadequate overall.

Following the most recent inspection we still rated the practice as inadequate and although some progress had been made, further improvements were required. The ratings for providing an effective service had improved from being inadequate to requiring improvement. The rating for providing a safe and well led service remained inadequate.

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

• Since our inspection in September 2015 there had been further changes in leadership and although there was a new vision and strategy there was still a lack of accountable, visible leadership.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents. However, the system still required improvement to ensure reviews and investigations were thorough, actions identified and implemented and learning disseminated in order to improve safety.
• The system for safeguarding children was not effective as there was not a consistent process in place to identify those at risk.
• The practice did not have an effective system in place for quality improvement (such as clinical audit) in order to monitor and improve patient outcomes.
• The practice had a number of policies and procedures to govern activity, but some were still in a draft format.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However there was no formal system in place to disseminate or discuss information such as NICE guidance to ensure all clinical staff were kept up to date.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had sought feedback from patients and had recently formed a patient participation group. They had acted on some of the feedback.
• Some risks to patients were assessed and identified actions implemented.

The areas where the provider must make improvements are:

• Ensure effective systems are in place for the management of patients on high risk medicines.

• Ensure effective processes for reporting, recording, acting on and monitoring significant events, incidents, near misses and complaints are in place in order to improve safety.

• Ensure all blank prescriptions are handled in accordance with national guidance.
• Implement an effective system for safeguarding children.
• Ensure an effective system is in place for quality improvement (such as clinical audit) in order to monitor and improve patient outcomes.
• Implement a system to ensure employment checks are carried out for staff including locums and appropriate indemnity is in place.
• Implement a formal system to disseminate and discuss NICE guidance to ensure all clinical staff are kept up to date.
• Address the issues highlighted in the national GP survey in order to improve patient satisfaction, including in respect of appointment access.

In addition the provider should:

• Ensure safety alerts are dealt with in line with the practice protocol.

• Ensure processes in place to check equipment is in date are followed.

• Review the storage of emergency medicines to ensure they are accessible in the case of an emergency.

This practice was placed in special measures on 4 February 2016. Insufficient improvements have been made such that there remains a rating of inadequate for the safe and well led domain. Therefore the practice will remain in special measures and kept under review. Another inspection will be conducted within six months to ensure the required improvements have been made. If the required improvements have not been made we will take action in line with our enforcement procedures.

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 Crossroads Medical Practice on 24 September 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing a safe, effective and well led service. It was rated as requires improvement for providing a responsive service and good for being caring. It was also rated as inadequate for providing services for, older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

The practice had undergone a number of staffing changes over the last 12 months and had found as a result of this a number of areas needed reviewing. They had started to put plans in place in some areas but these had not yet been fully implemented and therefore the proposed changes were not yet embedded. Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example there was not a robust system in place for the management of emergency equipment and medicines.

• Although some clinical audits had been carried out, these were not full audits. There was therefore no evidence that audits were driving improvement in performance to improve patient outcomes.
• The practice had not proactively sought feedback from staff or patients.
• The system in place for reporting incidents, near misses and concerns did not ensure that there was learning from incidents or that any potential learning was disseminated to staff.
• The systems in place for safeguarding children and vulnerable adults were not robust.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, the system in place for palliative care monitoring and review was not adequate.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• Urgent appointments were usually available on the day they were requested.
• The practice had limited leadership capacity and limited formal governance arrangements although this was largely due to recent changes in staffing.

The areas where the provider must make improvements are:

• Ensure risk profiling is being carried out to identify patients at a higher risk of an unplanned admission to hospital.

• Ensure there is a robust system in place for palliative care monitoring and review.

• Ensure there is a robust system in place for receiving, disseminating and acting on safety alerts.

• Ensure learning from significant events and complaints are shared with staff.

• Ensure all staff are up to date with training.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure fire drills and fire alarm testing are carried out regularly.

• Ensure there is a robust system in place for the management of emergency equipment and medicines.

• Ensure there are systems and processes in place for safeguarding children and vulnerable adults.

• Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.
• Ensure clinical audits are undertaken in the practice, including completed clinical audit or quality improvement cycles.
• Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• Ensure prescription pads are handled in accordance with national guidance.
• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
• Ensure all staff receive annual appraisals.

The areas where the provider should make improvement are:

• Ensure the Disaster Recovery Plan is up to date.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have not 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

This practice is rated as inadequate overall. (Previous rating 12/2017 requires improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Inadequate

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Crossroads Medical Practice in September 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

On 7 July 2016 we carried out an announced comprehensive inspection to ensure that sufficient improvement had been made. The practice continued to be rated as inadequate and remained in special measures.

An announced comprehensive inspection was undertaken following the second period of special measures on 9 March 2017. Overall the practice was rated as inadequate as insufficient improvements had been made.

We carried out an announced focussed inspection of Crossroads Medical Practice on 17 May 2017. We found at that inspection insufficient improvements had been made and the practice remained in special measures.

On 7 November 2017 we carried out an announced comprehensive inspection. The practice was rated as requires improvement and came out of special measures.

This announced comprehensive inspection of Crossroads Medical Practice was carried out on 11 September 2018.

At this inspection we found:

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not learn from them or consider how to improve their processes.
• Patients did not find the appointment system easy to use and reported that they were unable to access care when they needed it. Some patients we spoke with told us they struggled to get through to the practice by telephone; one called more than 40 times before they were able to speak to a staff member.
• Practice oversight of policies, procedures and risk assessments needed strengthening. Some policies were out of date, actions were unclear or needed follow up and risk assessments were not practice-specific.
• A quarter of patients with learning disabilities had received an annual review.
• Clinical resources had been invested in improving review rates for patients diagnosed with cancer. The practice offered patients double length appointment times and the unverified data showed this had improved significantly.
• Data quality needed to be improved as patient registers were not accurate. For example, the palliative care register contained details of patients who had survived cancer and the safeguarding children register was not up to date when compared to patient records.
• Clinicians managed high risk medicines effectively and completed monthly audits.
• Staff we spoke with told us they enjoyed working at the practice and despite challenges worked well as a team and felt supported by practice leaders.
• Patient satisfaction levels about clinicians had improved and patients had confidence and trust in the practice healthcare professionals. Patients felt they were treated with dignity and respect.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

• Take action so medicine reviews are carried out with a full review of the suitability of the medication.
• Develop a risk assessment for emergency medicines held.

I am placing this service back into 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