We carried out an announced comprehensive inspection at Crown Medical Centre on 19 March 2019 as part of our inspection programme.

At the last inspection in June 2018 we rated the practice as requires improvement overall.

We rated the practice as inadequate for providing safe services because:

• We found a significant backlog of patient records which needed to be summarised, and patient letters awaiting clinical coding.
• Recruitment checks for new employees did not always incorporate all of the required assurances.
• Competency assessments for health care assistants needed to be more extensive to provide evidence that key duties had been assessed and developed.

We rated the practice as requires improvement for well-led services because:

• Systems and processes to identify, assess and mitigate risks were not always operated effectively and overseen by managers and partners.

At this inspection in March 2019, we found that the provider had satisfactorily addressed these areas.

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 now rated this practice as good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

This practice is rated as requires improvement overall. (Previous rating published 6 February 2018 – Requires improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Crown Medical Centre on 19 June 2018. At the previous Care Quality Commission (CQC) inspection in September 2017, the practice received an overall requires improvement rating. The practice was deemed to require improvements for providing safe, responsive and well-led services, and good for providing effective and caring services. The practice provided us with an action plan to address the areas which we identified as problematic during this inspection. This inspection on 19 June 2018 was undertaken to check that the practice had made improvements and was compliant with regulations.

At this inspection we found:

• The practice had some systems to manage risk so that safety incidents were less likely to happen. However, not all risks were identified and acted upon appropriately.
• We found a significant backlog of patient records which required their notes summarising, and an additional backlog of letters which required clinical coding.
• Recruitment checks had not been sufficient and systems to ensure safe recruitment were found to be lacking. This included the screening of newly recruited staff through the Disclosure and Barring Service (DBS).
• The practice did not always take effective action when risks were identified. For example, we found that an action plan developed further to a fire risk assessment had not been reviewed almost two years after being issued.
• We found that there had been a significant improvement in the culture of the practice. At our previous inspection, some staff had raised concerns about how they were treated and did not feel that they received adequate support. Consequently, there had been a large turnover of staff which had disrupted the continuity of the service. However, we found the situation had improved and the appointment of a new practice manager was driving improvements to address many long-standing difficulties.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Most patients found the appointment system easy to use and reported that they were able to access care when they needed it. Feedback from the GP national survey was mostly in line with averages, although feedback received in CQC patient comment cards and other sources, such as NHS Choices, did not always support this view.
• There had been improvement in the handling of complaints within the practice.

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

• Ensure care and treatment is provided in a safe way to patients in accordance with the fundamental standards of care. For details, please refer to the requirement notice at the end of this report.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For details, please refer to the requirement notice at the end of this report.

The areas where the provider should make improvements are:

• Review the practice’s recall systems to improve patients’ attendance for review of long term conditions.
• Continue to review and improve access arrangements

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crown Medical Centre on 26 September 2016. The overall rating for the practice was requires improvement. The service was rated as requires improvement for being safe, responsive and well-led. The provider was issued with a requirement notice for a breach in regulations and was asked to provide us with an action plan. The full comprehensive report from the September 2016 inspection can be found on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Crown Medical Centre on 25 September 2017 to review the service and ensure that improvements had been made. Overall the practice rating remains as requires improvement.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. Significant events were regularly reviewed but systems were not always operated effectively to ensure learning was shared widely.
• There was a procedure to review and act upon patient safety information received from the Medicines and Healthcare Regulatory Agency (MHRA) to keep patients safe.
• Arrangements were in place to respond to emergencies, however, we identified that the practice did not have stocks of some medicines which might be required in the event of specific clinical emergencies.
• Arrangements for handling prescriptions needed to be strengthened to ensure these could be tracked through the practice in line with guidance.
• Staff told us that they assessed patients’ needs and delivered care in line with current evidence based guidance.
• The practice used clinical audit to drive quality improvement within the practice.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• The practice planned and co-ordinated patient care with the wider multi-disciplinary team, to deliver effective and responsive care to patients with complex health needs or those living in vulnerable circumstances.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients provided mixed views about their experience of making an appointment with the GP. Some patients told us that telephone access was problematic, and that it was difficult to book a GP appointment in advance. Urgent appointments were generally available on the same day. Continuity of care was highlighted as a difficulty by a number of patients as they were often seen by a different GP.
• The practice accommodated other services at Crown Medical Centre and at the branch site (Farnsfield Surgery) which provided care closer to patients' homes. This included community based clinics for physiotherapy, counselling and midwifery,
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about how to complain was available on request but was not clearly displayed in the patient waiting area at the branch site. There were some concerns with regard to the management of complaints.
• There was a clear leadership structure. However, staff provided mixed views about the level of support offered by management and the partners within the practice.
• The practice was a teaching practice for GP registrars. Educational workshops were also facilitated for clinicians within the local area.
• Some of the GP partners and nursing staff held strategic lead roles within the clinical commissioning group (CCG) executive and governing boards, which helped influence and drive improvement in the delivery of patient care within the locality.

The areas where the provider must make improvement are:

• Ensure the provision of safe care and treatment; specifically in respect of the arrangements to respond to emergencies and responding to areas of identified risk in respect of premises issues.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are employed to meet the needs of patients; ensure staff received appropriate support as is necessary to enable them to carry out their duties.

The areas where the provider should make improvement are:

• Improve the handling of blank prescriptions in line with guidance.
• Review and improve arrangements in place regarding staff appraisals.
• Continue to improve and embed the arrangements in place for acknowledging, investigating and responding to complaints.
• Consider the further development of a patient participation group
• Continue to review, monitor and act upon patient experience data to continually drive service improvement. This includes ensuring continuity of care 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 Crown Medical Centre on 29 September 2016. Overall the practice is rated as requires improvement.

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

• Prior to our inspection, the practice had identified the need for effective systems to be developed and embedded to improve the management of patient safety information, significant events and complaints as part of a quality improvement programme. An action plan was in place and we found some progress had been made in mitigating identified risks / concerns.

• We found improvements were still required in respect of reviewing and acting upon patient safety information received from the Medicines and Healthcare Regulatory Agency (MHRA) and NHS Improvement. In addition, the processes for analysing, reviewing and learning from significant events had not always been undertaken regularly or in a timely way and shared widely with the practice team.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• The practice had developed bespoke templates for use by clinicians when assessing or reviewing patient’s needs to ensure information gathering was in line with best practice. Some of these had been shared widely with other local GP practices.

• The practice used clinical audit to drive quality improvement within the practice.

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

• The practice planned and co-ordinated patient care with the wider multi-disciplinary team, to deliver effective and responsive care to patients with complex health needs or those living in vulnerable circumstances.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Most patients said they found it easy to make an appointment, with urgent appointments available the same day. However, patients felt continuity of care was not always maintained.

• The practice hosted additional services at Crown medical centre and Farnsfield surgery which provided care closer to patients' homes and reduced the burden on hospital services. This included community based clinics for physiotherapy, musculoskeletal conditions, counselling and podiatry.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Information about services and how to complain was available and some improvements had been made to the quality of care as a result of complaints and concerns.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvement are:

• Continue to assess and monitor the areas identified in the quality improvement programme to secure improvements. Specifically, ensure that systems and processes are established and operated effectively in respect of managing patient safety information/alerts, significant events and complaints.

• Ensure accurate, complete and up to date records relating to staff recruitment and employment, and the management of regulated activities are maintained.

The areas where the provider should make improvement are:

• Continue to review, monitor and act upon patient experience data to continually drive service improvement. This includes ensuring continuity of care for patients and usage of walk in services by patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice