We carried out an announced comprehensive inspection at Lees Medical Practice on 5 December 2018.

The practice had been inspected on 21 April 2017. It was rated as inadequate overall and placed in special measures. There were breaches in regulations 11, 12, 17 and 19. Requirement notices were issued for the breaches in regulations 11 and 19, and warning notices issued for the breaches in regulations 12 and 17.

On 3 October 2017 we carried out a focussed follow-up inspection to check that the practice had met the requirements of the warning notices. We found that not all issues had been addressed to a satisfactory standard.

On 20 December 2017 we carried out a comprehensive inspection to assess the progress the practice had made. We rated the practice as good overall, with safe being rated as requires improvement. Requirement notices were issued for breaches in regulations 12 and 19. The practice was taken out of special measures.

On 23 May 2018 we carried out a focussed follow up inspection to check progress had been made in relation to regulations 12 and 19. We found that the required improvements had been made and we rated the practice as good in the safe domain.

This was a full comprehensive inspection carried out on 5 December 2018 made 12 months after the practice was taken out of special measures. This was in accordance with our methodology to check the previous improvements made had been sustained.

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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• The practice did not carry out all the required checks prior to recruiting new staff.
• The infection control lead had not received specific training. A hand wash audit had been carried out by the untrained lead, but GPs had not been part of the audit.
• Test results had not been actioned in a timely manner.
• Evidence was not held that all staff, including clinicians, had received safeguarding training.
• Significant events were not well recorded. There was no clear plan when improvements were required, no timescales, and the person responsible for making changes was not recorded.

We rated the practice as requires improvement for providing effective services because:

• There was limited monitoring of the outcomes of care and treatment.
• There was no system to ensure care plans were regularly updated.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• The practice was unable to show evidence of improvement following clinical audits.
• The practice manager had not had an annual appraisal.

We rated the practice as requires improvement for providing caring services because:

• During the inspection we were informed that the practice did not register patients without an address. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this. 

• During the inspection we were informed that the practice did not know how to respond to changes in patients’ preferred gender, name or title. Following the inspection the practice told us this was incorrect and relevant requests had previously been actioned, but they provided us with no evidence to substantiate this.

• Information on the carer’s noticeboard was not up to date.

We rated the practice as requires improvement for providing responsive services because:

• Complaints were not managed in accordance with the policy. They were not used to improve the quality of care.

• During the inspection we were informed that there was no protocol for managing home visit requests with GPs having individual preferences. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this.

• During the inspection we were informed that there was no protocol for requests for urgent appointments. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this

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

• The practice had not sustained the improvements made since the previous CQC inspections.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• While the practice had a vision, that vision was not supported by a credible strategy.
• The overall governance arrangements were ineffective.
• Not all policies and procedures were followed.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure that any complaint received is investigated and necessary and proportionate action taken in response to any failure identified by the complaint or investigation.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively so only fit and proper persons are employed. Ensure specified information is available regarding each person employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review the policy for accepting vulnerable patient onto the practice register.
• Have a protocol for home visit and urgent appointment requests.
• Participate in social prescribing schemes.
• Review information displayed for patients and staff to make sure it is up to date.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 21 April 2017 we carried out a full comprehensive inspection of Lees Medical practice. This resulted in the practice being placed in special measures and Warning Notices being issued against the provider on 14 and 16 June 2017. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe care and treatment and Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Good governance.

On 3 October 2017 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. We found that not all issues had yet been addressed to a satisfactory standard. Although some improvement had been made and some systems had been introduced further improvements were still required to ensure that safety was maintained. In particular we found that :

• The practice introduced a new system for recording significant events in May 2017. However we found that there were still some improvements to be made to this system.

• The practice now used a local care plan system to identify high risk patients. Care plans had been created for patients living in nursing and residential care and the registered manager told us care plans were also in place for patients with chronic long term conditions and those at risk of unplanned hospital admissions. They told us they would provide further information about these by the end of the week of the inspection, but these were not provided.

• The provider carried out some safety checks and risk assessments. These included risk assessments carried out by external professional organisations such as a fire risk assessment, legionella risk assessment and emergency lighting annual check. However we found that there were still some improvements to be made to this system.

• The provider had initiated two clinical audits following our previous inspection. Both were in the initial stages of a first cycle.

• The provider had introduced a new process of induction for new staff; however we found that there were still some improvements to be made to this system.

• The provider had introduced a system to record staff training; however we found that there were still some improvements to be made to this system.

• We reviewed the ‘on the day’ urgent appointment system. We were told where cover was required locum GPs were available. We were also told that where children or vulnerable older patients required an appointment these would be accommodated on the day. We reviewed the appointment system for the following day and noted appointments were available.

The rating awarded to the practice following our full comprehensive inspection 21 April 2017 of ‘inadequate’ remains unchanged. The practice will be re-inspected in relation to their rating in the future.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection December 2017 – Good)

The key questions are rated as:

Are services safe? – Good

We carried out an announced focused inspection at Lees Medical Practice on 23 May 2018. When we inspected the practice on 20 December 2017 we rated the practice as good overall, and requires improvement in the safe domain. This inspection was to follow up on the breaches of regulation found, and also look at the areas where we identified improvements should be made.

At this inspection we found:

• The provider had reviewed their fire risk assessment and ensured all required actions had been completed.

• The provider ensured all the required information was available before a new employee started work.

• The provider had reviewed its policies to be practice specific.

• The provider had reviewed how they organised their electronic document storage. There was a common filing system that all staff could access.

• The provider had made the decision to have a Disclosure and Barring Service check for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice