We carried out an announced comprehensive inspection at Hove Medical Centre on 27 March 2019 as part of our inspection programme.

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 good overall and good for all population groups.

We found that:

• There were systems within the practice to assess, manage and mitigate risks.
• Patients received effective care and treatment that met their needs. There was evidence of improved patient outcomes.
• Staff training was monitored and training completion rates were high.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had made changes to the appointment system so that more appointments were available on the day. There was evidence of positive patient feedback about this.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• There was positive patient feedback with references to improvements being made.
• The way the practice was led and managed to promote the delivery of high-quality, person-centre care.
• There was no risk assessment of emergency medicines stored within the practice. The emergency medicines did not include a diuretic for the treatment of heart failure and there was no clear rationale for this.
• There was no log of safety alerts to record action taken in response to the alert. We saw evidence of alerts that practice staff had not been aware of.
• A significant event log and meeting minutes did not contain adequate detail to ensure ongoing monitoring of improvements and the identification of trends.
• GP patient survey results showed that the practice was below average in relation to patients feeling listened to and treated with care and concern. However, there was some evidence of improvement to patients’ general experience at the practice.

The areas where the provider must make improvement is:

• Ensure care and treatment is provided in a safe way to patients.

In addition, the provider should:

• Continue to work to improve areas of patient satisfaction such as in relation to patients feeling listened to and treated with care and concern.
• Review how significant events are recorded, including the amount of detail, to ensure that enough information is collated to support the review of events and the identification of trends.

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

We carried out an announced comprehensive inspection at Hove Medical Centre on 24 November 2017. The practice was rated good overall. However, we found that the practice required improvement for the provision of safe services because breaches of regulation were identified. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Hove Medical Centre on our website at www.cqc.org.uk

Specifically, we said they must:

• Ensure that care and treatment is provided in a safe way for service users, by completing and recording the outcome of the legionella risk assessment.

In addition we said the provider should:

• Continue to update practice policies and improve the electronic filing system to ease navigation.

• Improve the training matrix for showing mandatory training requirements.

• Continue to improve patient satisfaction results.

After the previous focused inspection on 24 November 2017, the practice wrote to us to say what they would do to meet legal requirements. We undertook this focused inspection on 09 March 2018 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

Overall the practice continues to be rated as good and is now good in the safe domain.

Our key findings for this inspection were as follows:

• There was a clear legionella risk assessment in place detailing actions and outcomes.

• Practice policies were up to date and the electronic filing system was easy to navigate and recognised when staff had read each policy.

• The practice had adopted a new matrix which clearly showed when mandatory training was due for each staff member.

• The practice continued to find ways to improve their patient satisfaction results. For example a recent survey showed that patients’ satisfaction with access to appointments had significantly improved.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Hove Medical Centre was previously inspected on 29 November 2016 and was rated as requires improvement overall and for safe, effective and responsive services and good for caring and well-led services.

At this inspection on 24 November 2017 the practice is rated as good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

We undertook a comprehensive inspection of Hove Medical Centre on 29 November 2016 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as requires improvement for providing safe, effective and responsive services.

We undertook a further announced comprehensive inspection of Hove Medical Centre on 24 November 2017. This inspection was carried out to ensure improvements had been made and to provide a further rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had an open and transparent approach to safety but did not always have sufficient effective systems and processes in place to ensure patients were always kept safe. For example, the practice had not completed the required actions after the legionella assessment.

• Staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses. The practice had an appropriate system for recording significant events.

• The practice was able to demonstrate that all staff were up to date with essential training. However, the training matrix adopted by the practice was not always fit for purpose.

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

• Data from the Quality and Outcomes Framework (QOF) showed the results for the management of patients with long-term conditions were good.

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

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment

• Patients said they were able to book an appointment that suited their needs. Pre-bookable, on the day appointments, home visits and a telephone consultation service were available. Urgent appointments for those with enhanced needs were also provided the same day. Patients commented on the much improved service in recent months.

• The practice was equipped to treat patients and meet their needs.

• Staff told us they felt well supported and enjoyed working at the practice.

• We observed the premises to be visibly clean and tidy.

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

• Ensure that care and treatment is provided in a safe way for service users, by completing and recording the outcome of the Legionella assessment.

The areas where the provider should make improvements are:

• Continue to update practice policies and improve the electronic filing system to ease navigation.

• Improve the training matrix for showing mandatory training requirements.

• Continue to improve patient satisfaction results.

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 Hove Medical Centre on 31 March 2016 where breaches to regulations were identified and warning notices were issued and the practice rated as inadequate. The practice was placed in special measures. A focused inspection was carried out on 4 August 2016 where it was identified that the legal requirements of the issued warning notices had been met. We carried out a further comprehensive inspection on 29 November 2016. Overall the practice is rated as requires improvement and for safe, effective and responsive services. They are good in caring and well-led services.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Improvements had been made to recording and learning from significant events.
• Improvements had been made to the availability of policies relating to safeguarding and staff had been trained to a suitable level for their role.
• The practice had clearly defined and embedded systems to minimise risks to patient safety, however, not all risks relating to infection control had been addressed.
• The practice had made improvements to training and induction processes and there were plans to further these improvements; however records showed there continued to be some gaps in staff training and induction.
• Improvements had been made to fire safety within the practice.
• Recruitment records were maintained and improvements had been made to the checks carried out prior to employment.
• Electrical and calibration records were available and demonstrated improvements within this area.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patient outcomes were mixed in some areas; however the practice had identified lead staff to make improvements in this area including improving the patient recall system.
• There was evidence of improvements to clinical audits within the practice with examples of full cycle audits leading to improved patient outcomes.
• Patients we spoke with told us they were treated with compassion, dignity and respect; however results from the national GP patient survey showed mixed results relating to this and patients feeling involved in their care and decisions about their treatment.
• The practice had developed their own PPG and had held meetings where patients were able to provide feedback. As a result the practice had a clear action plan to address areas of concern.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. The practice had taken action to improve telephone access to the practice in response to patient feedback.
• 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. Staff and patients recognised recent improvements within the practice.
• The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure improvements are made relating to assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those relating to baby changing facilities and the disposal of sharps bins.
• Ensure that persons employed in the provision of the regulated activity receive such appropriate support in relation training and induction and that these are appropriately recorded.

The areas where the provider should make improvement are:

• Have regard for the results of the GP patient survey in relation to consultations and take action to make improvements.
• Continue to monitor and address patient feedback relating to access to appointments.
• Continue to embed the process for monitoring trends relating to significant events.
• Record the practice strategy and business plans.
• Continue to improve diabetes performance in relation to QOF.
• Continue to improve the percentage of patients with dementia who receive a face to face review.

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 comprehensive inspection of this practice on 31 March 2016. Breaches of legal requirements were found in relation to the safe storage and monitoring of medicines and vaccines, maintenance of the premises and equipment, governance arrangements, and recruitment procedures. We issued the practice with three warning notices requiring them to achieve compliance with the regulations set out in those warning notices by 12 August 2016. We undertook this focused inspection on 4 August 2016 to check that they now met the legal requirements. This report only covers our findings in relation to those requirements.

At this inspection we found that the requirements of the three warning notices had been met.

Our key findings across the areas we inspected for this focused inspection were as follows:

• The practice had made considerable improvements since our last inspection. We saw there was now an effective system in place for reporting and recording significant events.

• The arrangements for monitoring and storing medicines in the practice kept patients safe. This included that we found that medicines and vaccines were stored in line with national guidance, equipment we checked was in date and fit for use, and staff demonstrated a sound understanding of the safe storage of vaccines.

• Risks to patients were assessed and well managed. The practice maintained appropriate standards of cleanliness and hygiene. A variety of risk assessments had been completed to monitor safety and maintenance of the premises. Fire alarms had been installed and were tested weekly and regular fire drills were conducted.

• We found that almost all recruitment checks had been completed, including checks with a relevant professional body. The partners were working towards fully updating all of the personnel files.

• There was a clear leadership structure and staff felt supported, particularly by partners. They told us that the culture of the practice had change dramatically since our last inspection and communication had improved. Staff told us they were regularly offered support both formally and informally.
• The practice proactively sought feedback from staff and patients, which it acted on. They had initiated a patient participation group and continued to contribute to a local health forum.

The areas where the provider must make improvements are:

• Ensure staff files are kept up to date with recruitment checks completed, including checks with the relevant professional body.

The areas where the provider should make improvements are:

• Ensure cleaning of ear irrigation equipment is recorded within cleaning logs.

• Ensure that any actions recommended from the legionella risk assessment are recorded and monitored.

• Formally document the practice business plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an inspection in November 2013 and found shortfalls in infection control procedures and recruitment of staff. Following the inspection the provider wrote to us to tell us what action they would take to meet these shortfalls.

We carried out this announced inspection on 18 September 2014 to check on the actions the provider had taken. The inspection team consisted of a CQC inspector and a practice nurse.

We found that improvements had been made to infection control and staff recruitment procedures and the practice was complaint with the regulations.

We spoke with the practice manager, two GP’s (one of whom was the registered manager), two nurses and three receptionists. We also interviewed six patients who attended the practice on the day of our inspection.

We found people’s privacy and dignity were respected. Patients were given information to help them be involved in their care. One patient said to us, “I think the doctor is really good; the doctor makes sure that he explains everything to me.” However, some patients we spoke with did not feel they were listened to. One said, “I don’t think the doctor listens to me, so I don’t feel confident about what they say.”

We saw that patients’ records supported safe and effective clinical care. There were systems for managing patients’ medicines safely and for ensuring investigation results were followed up. Patients expressed confidence in their care, with one commenting, “I’ve been coming here for years; I’m comfortable and happy with the way things are. They’re very good, the doctors”. However, some patients we spoke with were less positive. One comment received was, “I don’t feel that the doctors are that good. They don’t listen to me that much.”

Patients felt that obtaining appointments could be difficult. One said, “You never can get an appointment in under a week.” However, we found that patients could access appointments if their need was urgent. A receptionist said, “We have regular appointment slots for people, but if something is urgent, then the doctor will phone them that day and they are called in. We never refuse anybody.”

We found that not all government guidance relating to infection prevention and control was being followed.

We found that there were no robust arrangements for checking that the professional registration of GP’s and nurses remained current. There was no system for assessing the need for staff background checks.

We found there were arrangements in place to assess and monitor the quality of service provided. We found changes were made in light of complaints and critical incidents.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hove Medical Centre on 31 March 2016. Overall the practice is rated as inadequate.

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. However, the practice did not demonstrate that significant events or complaints were always thoroughly recorded, analysed and appropriately stored, or that learning was shared effectively with staff.
• Risks to patients, staff and visitors to the practice were not all assessed or well managed. This included; the practice did not ensure cleanliness was monitored, did not have fire alarms and had not conducted a fire risk assessment, no legionella or health and safety risk assessments had been completed, and no electrical safety tests had been conducted.
• Data showed patient outcomes were mixed compared to local and national patient outcomes. Evidence was hard to identify as little reference was made to audits or quality improvement.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, vaccines and medicines were not all stored or managed in line with national guidance.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt they were listened to or given enough time at their appointment.
• Urgent appointments were usually available on the day they were requested. However appointment systems were not working well so patients reported that they did not receive timely care when they needed it.
• The practice had a number of policies and procedures to govern activity.
• There was a leadership structure in place and most staff felt supported, but this was not always by management. All staff spoke positively about working at the practice.

The areas where the provider must make improvements are:

• Ensure that there are robust processes for reporting, recording, acting on and monitoring significant events, incidents and complaints. Ensure that lessons learnt from complaints and significant events are communicated to the appropriate staff to support improvement at all levels.
• Ensure risk assessments are completed including health and safety, legionella, electrical safety, and fire risks. This includes that an assessment of cleanliness is regularly completed, and that cleaning undertaken is recorded and monitored.
• Ensure that information security policy and process is in place to ensure that confidential patient records are accessed and stored in accordance with national guidelines.
• Ensure that all documents and processes used to govern activity are practice specific and are up to date. This includes adult safeguarding arrangements, and the use of patient specific directives when authorising clinical staff to administer vaccines and immunisations.
• Ensure all the learning and development needs of all staff are identified through a system of comprehensive induction, annual appraisals, and meetings, which are recorded and monitored. Ensure all staff are up to date with attending mandatory training courses; including adult and child safeguarding, information governance, and Deprivation of Liberty safeguards as part of the Mental Capacity Act 2005.
• Ensure the practice has robust medicines management processes and policy, to include that national guidance is followed when storing vaccines and medicines, and to ensure medical equipment is monitored and fit for use. Improve policies and procedures to ensure the security and tracking of blank prescriptions at all times. Ensure all clinical waste is correctly documented and disposed of safely in order to minimise the risks of improper disposal.
• Maintain records of all practice meetings including clinical, multidisciplinary, practice and significant events discussions to evidence the on-going care and treatment of patients and improvement of service.
• Ensure that recruitment checks, including proof of identification and references, are completed and retained as set out in the practice recruitment policy. Ensure that registration checks are completed with the appropriate professional body for clinical staff and in a timely manner.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed in order to meet patients’ care and treatment needs, particularly during periods of absence.
• Carry out an on-going audit programme to show that continuous improvements have been made to patient care in a range of clinical areas as a result of clinical audit.
• Ensure that all patients are treated with respect and dignity at all times, including on the telephone and at appointments. Review the availability of disposable curtains in treatment rooms and consultation rooms and ensure curtains are installed in rooms with sufficient space. Review patient privacy within the waiting area and reception desk.
• Review and improve the telephone booking system, availability of appointments and length of time allocated for appointments for patient consultations and treatment.
• Revise how the practice gathers feedback to ensure that patients and staff are involved with how the practice is run.
• Develop, document and communicate to all staff the practice governance, vision, strategy and supporting business plan. Clearly define the individual roles and responsibilities of each management staff member, including partners, within a leadership staffing structure. Revise the support mechanisms available to staff and provide arrangements for all staff to attend formal meetings and clinical supervision.

In addition the provider should:

• Continue to ensure that all staff are either risk assessed or have received a disclosure and barring (DBS) check especially for staff who act as chaperones.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains 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.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice