Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Meanwhile Garden Medical Centre, for areas within the key question effective. This review was completed on 15 December 2016. The practice is rated as good overall and in all five key domains.

We undertook a comprehensive inspection of Meanwhile Garden Medical Centre on 7 July 2015. The practice was rated as overall inadequate. Due to the inadequate rating the practice was placed in special measures. Two warning notices and two requirement notices were also issued.

We then carried out an announced comprehensive inspection on 12 April 2016 to consider if all regulatory breaches in the July 2015 inspection had been addressed and to consider whether sufficient improvements had been made to bring the practice out of special measures.

At the inspection in April 2016 we found significant improvements had been made and overall the practice was rated as good. However, the key question effective was identified as ‘requires improvement’, as the practice was not meeting the legislation around mental capacity. The practice was issued a requirement notice under Regulation 11, Need for Consent.

Although staff had received training in relation to consent, not all staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.

After our inspection in April 2016 the practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 11 Need for Consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

However, at the time of the desk top review, the practice had not displayed CQC performance ratings on their website in line with Regulation 20A.

The area where the practice should make improvements is:

• Display the details of CQC’s website, the most recent CQC rating and the date it was given on the Meanwhile Garden Medical Centre website.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of Meanwhile Garden Medical Centre on 7 July 2015. The practice was rated as inadequate overall. Due to the inadequate rating the practice was placed in special measures. Two warning notices and two requirement notices were also issued. We then carried out an announced comprehensive inspection on 12 April 2016 to consider if all regulatory breaches in the July 2015 inspection had been addressed and to consider whether sufficient improvements had been made to bring the practice out of special measures.

At this inspection we found significant improvements had been made and overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However not all clinical staff had a knowledge of the Mental Capacity Act 2005.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients 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 adequate facilities and was equipped to treat patients and meet their needs.
• 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure all clinical staff have an adequate knowledge of the Mental Capacity Act 2005 specifically in relation to best interest decisions and mental capacity assessments.

On the findings of this inspection 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 at Meanwhile Garden Medical Centre on 7 July 2015. Overall the practice is rated as inadequate.

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

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 incident reporting, safeguarding, recruitment, infection control and medicine management.
• Systems were not in place to monitor safety and respond to risk.
• There was insufficient assurance to demonstrate patients received effective care and treatment. The National Institute for Health and Care Excellence (NICE) guidance was not always followed, clinical performance was not monitored and clinical audit not carried out to evaluate and improve outcomes for patients.
• The majority of patients said they were treated with compassion, dignity and respect.
• There was limited engagement with local commissioners to discuss service improvements.
• Patients reported positively in terms of access to appointments.
• The practice did not actively engage with patients and staff to seek feedback.
• Leadership was fragmented and there was no clear leadership structure in place.

The areas where the provider needs to make improvements are;

Importantly, the provider must:

• Introduce robust procedures for reporting, recording, acting on and monitoring significant events, incidents and near misses, ensure learning is shared with all staff and safety alerts received by the practice are acted on where appropriate. Ensure robust systems are in place for safeguarding children and adults.
• Ensure staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out their duties they are employed to perform including providing clinical care and treatment in line with national guidance and guidelines.
• Ensure recruitment arrangements include all necessary employment checks for all staff and document all recruitment and employment information in staff files.
• Ensure all vaccine fridges are temperature monitored and daily temperature checks recorded.
• Establish effective systems, including monitoring and regular audit of practice, to meet current guidance to ensure infection prevention and control measures are met and the cleanliness and hygiene of the practice is maintained and assured. Introduce a legionella risk assessment and related management schedule.
• Implement a system to monitor health and safety in the practice including risk assessments for fire and the general environment. Provide staff with fire safety training and carry out regular fire drills to test the fire evacuation procedures.
• Provide access to an automated external defibrillator (AED) or carry out a risk assessment to assess the risk of not having access to this equipment.
• Develop a business continuity plan to ensure continuity of services in the event of a major disruption to the service.
• Proactively monitor the Quality and Outcomes Framework (QOF) performance to steer practice activity and carry out clinical audit to drive improvement in patient outcomes.
• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision. Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which is reflective of the requirements of the practice. Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements. The service must seek and act on feedback from staff, patients and external agencies on the services provided and evaluate and improve their practice in respect of this information.

In addition the provider should:

• Develop a website as an additional means to provide information about the practice to patients.
• Provide more detailed information on the practices’ complaints procedure including external organisations patients can contact.
• Schedule in longer appointment slots for more vulnerable patients.
• Repair the light cord in the disabled toilet.
• Ensure patients are sufficiently involved in decisions about their treatment and care.
• Ensure patients are treated with care and concern by all staff.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Meanwhile Garden Medical Centre on 2 April 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service is 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.

• 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 we spoke with were positive about working at the practice and the leadership and management team.
• 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.
• There were innovative approaches to providing integrated person-centred care tailored to meet the needs of substance mis-use patients.
• The practice promoted good health and prevention and provided patients with suitable advice and guidance.

The areas where the provider should make improvements are:

• Review the practice definition of significant events to ensure that all staff were clear about what should be recorded as one.
• Continue to implement processes to improve the take up of childhood immunisations.
• Continue to identify Carers to ensure they receive appropriate support.

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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