We previously carried out an announced comprehensive inspection at Meir Park Surgery on 6 March 2019 as part of our inspection programme. The practice was rated inadequate, placed into special measures and a warning notice in relation to safe care and treatment was issued. The full comprehensive report on the March 2019 inspection can be found by selecting the ‘all reports’ link for Meir Park Surgery on our website at .

We carried out an announced focused inspection at Meir Park Surgery on 30 April 2019 to ensure that the issues identified in the warning notice had been addressed. This report only covers our findings in relation to the warning notice.

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.
• information from the provider, patients and other organisations.

We found that:

• Suggested emergency medicines were available at the branch practice.
• Medicines and Healthcare products Regulatory Agency (MHRA) alerts were acted upon.
• Clinical and non-clinical staff had completed the appropriate level of safeguarding children and vulnerable adults training for their roles.
• Non-clinical staff were trained in identifying deteriorating or acutely unwell patients suffering from potential illnesses such a sepsis.
• All staff who acted as chaperones were trained for this role.
• Staff who acted as fire marshals had received the required training.
• All staff had received training on infection prevention and control.
• The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or children who were frequent A&E attenders.
• Patients potentially in the pre-diabetic stage had been coded appropriately within the practice’s computer system and received appropriate life-style advise.
• There had been improvements in recruitment checks however, health assessments were not always completed.
• The practice had processes for monitoring patients prescribed high risk medicines however, they needed to consider alternative ways to promote patient compliance with blood test monitoring.
• Children’s safeguarding meetings with other agencies had not been held.
• A system of reconciling children at risk of harm, as identified by the practice, with health visitors and school nurses was not in place.

At this inspection, we found that the provider had satisfactorily addressed most of the issues identified in the warning notice. However, there were areas where the provider remains in breach and must make improvements that we will follow up at our next inspection:

• Complete risk assessments for staff who have not received a health assessment.
• Implement systems to promote patient compliance with required blood test monitoring.
• Establish safeguarding meetings with other agencies.
• Reconcile the practice’s list of children at risk of harm with appropriate agencies.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

We carried out an announced comprehensive inspection at Meir Park Surgery on 6 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 inadequate overall and requires improvement for all population groups.

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

• Staff had not been made aware of the most up to date safeguarding policies and procedures to refer to or where to locate them.
• Some clinical and non-clinical staff had not completed safeguarding training appropriate to their role. Not all staff who acted as chaperones were trained for this role.
• Regular safeguarding meetings with other agencies had not been held and a system of reconciling children at risk of harm identified by the practice with health visitors and school nurses was not in place. The practice did not have arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or frequent A&E attendances.
• Recruitment checks had not always been carried out in accordance with regulations.
• Two members of staff who acted as fire marshals had not received the required training. Not all staff had received training on infection prevention and control. Non-clinical staff had not been provided with training to make them aware of possible signs of sepsis.
• Not all the suggested emergency medicines were available at the branch practice. A risk assessment to mitigate potential risks to patients had not been completed. The process for monitoring patients prescribed high risk medicines was not always effective. Appropriate monitoring and clinical review prior to prescribing was not always completed.
• Medicines and Healthcare products Regulatory Agency (MHRA) alerts were not always acted upon.
• A system for sharing learning from significant events with staff was not in place.

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

• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation.
• The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.

However:

• We identified 248 patients in the potentially pre-diabetic stage who had not been coded appropriately within the practice’s computer system or received life style advise.
• The practice did not have arrangements for following up failed attendance of children’s appointments following an appointment in secondary care.
• There were multiple gaps in staff training in relation to equality and diversity, basic life support, fire safety, mental capacity act, health and safety and safeguarding vulnerable adults and children.

We rated the practice as good for providing caring services because:

• Staff treated patients with kindness, respect and compassion.
• The practice respected patients’ privacy and dignity.

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

• Patient satisfaction with access to appointments was significantly below the national average.
• A system was not in place to follow up children and young people with a high number of accident and emergency attendances or children who failed to attend hospital appointments.
• There was no system in place to share learning from complaints with staff across both sites.

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

• Action plans to address the challenges faced by the practice were not in place. This included succession planning and delivery of the service in relation to very low patient satisfaction with access to appointments.
• Staff were not aware of the practice’s vision.
• There were very low levels of staff satisfaction and high levels of stress across both practices. Staff did not feel that their views were listened to or valued.
• Staff were confused regarding where they would locate the most up to date policies.
• An overarching system to monitor staff compliance with essential training was not in place.
• A system of sharing learning from significant events and complaints with staff was not in place.
• Five of the eight recommendations we made at our previous inspection had not been fully implemented.

The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The provider should:

• Improve access to interpretation services at the main practice.
• Identify ways of improving access to appointments.
• Record in patients’ notes that blood test results have been checked by a GP and are within a safe therapeutic stage before issuing repeat prescriptions for methotrexate.

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

I am placing this service in 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.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We inspected this service on 5 December 2014 as part of our new comprehensive inspection programme.

The overall rating for this practice is good. We found the practice to be good in the safe, effective, caring, responsive and well led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, people whose circumstances may make them vulnerable and working age people but requires improvement for people experiencing poor mental health.

Our key findings were as follows:

• There were arrangements in place for staff to report and learn from key safety risks. The practice had a system in place for reporting, recording and investigating significant events but needs to develop a system to monitor significant events over time.
• There were systems in place to keep patients safe from the risk and spread of infection however, a system should be put in place to ensure the cleaning of portable screens used to maintain patient’s dignity and privacy. Systems were in place to monitor and make required improvements to the practice when required.
• Patients were satisfied with how they were treated and this was with compassion, dignity and respect.
• Most patients told us they were satisfied with the appointments system and that it met their needs.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Introduce a system to review significant events and complaints overtime to detect themes or trends.
• Ensure that all staff receive training in safeguarding vulnerable adults.
• Introduce a system to ensure that patients who require a follow up appointment following abnormal test results are appropriately followed up.
• Introduce a system to ensure that the portable screens used to provide privacy during an intimate examination are cleaned regularly.
• Introduce a system to check that professional registrations are current and in date.
• Ensure that patients experiencing poor mental health and patients with dementia are provided with an annual health review.
• Introduce a system for reviewing policies to ensure they are current and up to date.
• Develop a long term business plan incorporating potential risks to the practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

On the day of our inspection we spoke with eight patients and six members of staff. Prior to our inspection we spoke with a spokesperson from the patient participation group (PPG) who was also a patient. PPGs are an effective way for patients and GP practices to work together to improve the service and to promote and improve the quality of the care. One patient told us, “They are fabulous. They have always done everything I have asked for”. Another patient told us, “It is very good here, I have been treated well. Getting an appointment is difficult though”.

We saw that patient’s views and experiences were taken into account in the way the service was provided and that patients were treated with dignity and respect. We saw that patients experienced care, treatment and support that met their needs.

Staff had received training in safeguarding children but not safeguarding vulnerable adults. They were aware of the appropriate agencies to refer safeguarding concerns to so that patients were protected from harm.

The provider did not have systems in place to ensure patients were cared for by suitably qualified professional staff because checks to ensure that staff were suitable to carry out their role had not always been completed. We saw one member of staff had not gone through a formal interview process.

We saw the provider had an effective system to regularly assess and monitor the quality of the service that patients received and had effectively gathered and acted on the views of patients who used the service.