Sleaford Medical Group (the provider) had been inspected previously on the following dates:

• 13 April 2017 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months. Breaches of legal requirements were found in relation to governance arrangements within the practice. A warning notice was issued which required them to achieve compliance with the regulations set out in the warning notice by 24 August 2017.

• 20 September 2017 - A focused inspection was undertaken to check that they now met the legal requirements. As the practice had not made all the improvements to achieve compliance with the regulations a letter of concern was sent, and action plans were requested on a fortnightly basis to ensure the required improvements had been put in place.

• 19 December 2017 - inspection was undertaken following a six-month period of special measures and was an announced comprehensive. Insufficient improvements had been made and the practice were still inadequate overall and remained in special measures for a further six months. Conditions were added to the providers registration and we took action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This would have led to cancelling their registration or to varying the terms of their registration within six months if they did not improve. The service was kept under review.

• 20 March 2018 – inspection was undertaken to check that Sleaford Medical Group had now met the legal requirements of the Notice of Decision to impose conditions on their registration which was served on 22 December 2017 in relation to medication reviews. The practice had taken significant steps in order to ensure patients health was monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately. The Care Quality Commission removed the conditions from their registration and the notice of decision to cancel their registration was withdrawn.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Sleaford Medical Group on our website at .

This inspection was undertaken following a six-month period of special measures and was an announced comprehensive inspection on 19 July 2018.

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

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

At this inspection we found:

• Sleaford Medical Group demonstrated that they had been responsive to the findings of the previous reports and were able to evidence that improvements had been made. We saw that clinical leadership had been improved and GP partners and practice staff we spoke with had been fully engaged in the changes that had been made. We spoke with external partners, for example, SouthWest Lincolnshire Clinical Commissioning Group who told us the practice had been engaged and supported they had provided support where appropriate.
• We found that the systems in place for reporting and recording significant events and complaints had been improved but further work was required to ensure the systems were effective.
• The practice had reliable systems for appropriate and safe handling of medicines.
• Patients’ health was now monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately.
• The practice routinely 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.
• Since the last inspection the practice had formed a new patient participation group who were very positive and told us the focus of the group was around engagement and improving services.
• The practice had made improvements to their governance arrangements and had taken some of the appropriate steps required to ensure patients remained safe. Further time was required to ensure all the improvements were embedded.
• There was a now focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to work to improve the process for significant events and ensure learning is discussed and documented.
• Complete remedial work in regard to fire safety and advise the Care Quality Commission when this has been completed.
• Embed the new processes for handling complaints to ensure complaints are dealt with in a timely way.
• Review the system for recording verbal complaints to ensure themes and trends are identified and discussed.
• Review the carers register to ensure it is accurate and up to date.
• Continue to embed the new process for nurse clinical supervision and ensure debriefs are minuted.
• Ensure all staff appraisals are completed and put in staff files for information.
• Work to improve and review patient satisfaction and respond to reviews where appropriate
• Improve the recruitment process to ensure that references and document checks on professional registration are routinely carried out.

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

Please refer to the detailed report and the evidence tables for further information

Sleaford Medical Group (the provider) had been inspected previously on the following dates:

• 13 April 2017 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months. Breaches of legal requirements were found in relation to governance arrangements within the practice. A warning notice was issued which required them to achieve compliance with the regulations set out in the warning notice by 24 August 2017.

• 20 September 2017 - A focused inspection was undertaken to check that they now met the legal requirements. As the practice had not made all the improvements to achieve compliance with the regulations a letter of concern was sent, and action plans were requested on a fortnightly basis to ensure the required improvements had been put in place.

• 19 December 2017 – a comprehensive inspection following a six month period of special measures. Insufficient improvements have been made such that there remains a rating of inadequate for this inspection. The practice was placed in special measures for a further period of six months. The Care Quality Commission therefore took 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.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Sleaford Medical Group on our website at www.cqc.org.uk.

We undertook this unannounced focused inspection on 20 March 2018 to check that they had now met the legal requirements of the Notice of Decision to impose conditions on their registration which was served on 22 December 2017 in relation to medication reviews. This report only covers our findings in relation to those requirements.

Our key findings from the areas we inspected for this focussed inspection were as follows:

• Since the inspection in December 2017 the practice had taken significant steps in order to ensure patients health was monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately.

• New processes were in place and at the time of this inspection the practice had monitoring systems in place to ensure they were effective and kept patients safe from harm.

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

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The service will be kept under review and another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Sleaford Medical Group (the provider) had been inspected previously on the following dates:

• 13 April 2017 under the comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months. Breaches of legal requirements were found in relation to governance arrangements within the practice. A warning notice was issued which required them to achieve compliance with the regulations set out in the warning notice by 24 August 2017.

• 20 September 2017 - A focused inspection was undertaken to check that they now met the legal requirements. As the practice had not made all the improvements to achieve compliance with the regulations a letter of concern was sent, and action plans were requested on a fortnightly basis to ensure the required improvements had been put in place.

Reports from our previous inspections can be found by selecting the ‘all reports’ link for Sleaford Medical Group on our website at www.cqc.org.uk.

This inspection was undertaken following a six month period of special measures and was an announced comprehensive inspection on 19 December 2017.

This practice is still rated as inadequate overall. (Previous inspection April 2017 was Inadequate).

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The provider was rated as inadequate for safe, responsive and well led services and requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

At this inspection we found:

• Staff understood their responsibilities to raise concerns and report incidents. These were discussed with relevant staff on a regular basis. However, further improvements were still required in the investigation and analysis of significant events in order to correctly identify appropriate and relevant learning from incidents , review of common themes and ensure that necessary actions were taken. For example, missed referrals.

• Patients’ health was not always monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately.

• Most Disclosure and Barring checks were in place with the exception of a locum GP and a medicine delivery driver.Since the inspection the practice have told us the DBS checks are now in place.

• The practice had made improvements to their governance arrangements and had taken some of the appropriate steps required to ensure patients remained safe. Further work was still required in regard to significant events quality improvement to improve patient outcomes and dealing with complaints.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients we spoke with told us they found it difficult to use the appointment system. This aligned with the results of the national patient survey as only 64% describe their experience of making an appointment as good compared to the local (CCG) average of 75% and national average of 73%.

• The new processes introduced in respect of complaints required further embedding to ensure all complaints were captured, investigated and appropriate learning identified, shared and acted upon.

• At this inspection we still had concerns in regard to the clinical oversight and governance arrangements in place.

• There was limited quality improvement.

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.

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

• Complete actions from the infection control audit
• Ensure fire safety testing and legionella water monitoring is carried out as per practice policies.
• Improve the monitoring of prescribing to ensure it is in line with national clinical guidance and current best practice. For example, antimicrobial prescribing.
• Consider a review of the process for consent to ensure it is accurately recorded on the patient record.
• Ensure the nurse practitioner has regular clinical supervision.
• Ensure meeting minutes contain details of the discussions that have taken place.
• Review the system in place for tracking blank prescription forms and pads to ensure it meets the recommendations set out in current national guidance

This service was placed in special measures on 6 July 2017. Insufficient improvements have been made such that there remains a rating of inadequate for this inspection.

Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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 13 April 2017.

Breaches of legal requirements were found in relation to governance arrangements within the practice. We issued the practice with a warning notice requiring them to achieve compliance with the regulations set out in those warning notices by 24 August 2017.

We undertook this focused inspection on 27 September 2017 to check that they now met the legal requirements. This report only covers our findings in relation to those requirements.

At the inspection on 27 September we found that not all the requirements of the warning notice had been met.

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

• The practice had made improvements to their governance arrangements and had taken some of the appropriate steps required to ensure patients remained safe. Further work was required in regard to significant events, medicine reviews including high risk medicines and complaints.

• Safe systems were now in place for patient safety alerts, monitoring of the cold chain and the management of patients with a suspected urinary tract infection (UTI).

• Improvements had been put in place in regard to governance arrangements and some of the appropriate steps required had been taken to ensure patients remained safe.

• The leadership structure had strengthened considerably and areas of responsibility had been identified. There was an updated documented leadership structure and it was clear who took overall responsibility for the surgery.

As the legal requirements of the warning notice were not met the Care Quality Commission has sent the practice a letter of concern in which we require them to send us fortnightly action plans.

The areas where the provider must make improvements are:-

• Continue to review the system in place for significant events to ensure all events are captured, investigations are detailed, actions are identified and implemented.

• Further improve the process in place for the management of risks to patients and others against inappropriate or unsafe care. This should include: medication reviews and the monitoring of patients on high risk medicines,
• Further consolidate the complaints process and ensure learning from complaints are discussed and shared. Ensure trends are analysed and action is taken to improve the quality of care as a result.

In addition the provider should:

• Ensure there is leadership capacity to deliver all the improvements

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 Sleaford Medical Group on 13 April 2017.

Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because some systems and processes in place were not effective to keep them safe. For example, patient safety alerts, monitoring of patients on high risk medicines, medication reviews, monitoring of the cold chain and management of patients with urinary tract infections.

• Risk were assessed and well managed.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, learning and dissemination in relation to significant events and complaints was not always effective.

• The practice had a system in place to keep patients safe and safeguarded from abuse. However some staff were not up to date with safeguarding training.

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

• The July 2016 national patient survey results had not been reviewed and actions put in place to improve the areas of concerns identified by the patients registered at the practice.

• Most of the national patient survey results from July 2016 were below national and CCG average results.
• Comments cards we reviewed told us that patients said they were treated with compassion, dignity and respect. They felt cared for, supported and listened to.
• The practice did not have an active patient participation group and there was limited evidence to demonstrate that they proactively sought feedback from patients and staff.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review.
• There was no overarching governance framework in place to support the delivery of the strategy and good quality care.

• There was a documented leadership structure but it was not clear who took overall responsibility for the surgery.

The areas where the provider must make improvements are:

• Improve the process in place for the management of risks to patients and others against inappropriate or unsafe care. This should include: patient safety alerts, monitoring of patients on high risk medicines, medication reviews, monitoring of the cold chain and management of patients with urinary tract infections.

• Ensure pathology results are reviewed to ensure action is taken where appropriate and they are filed on the patient record in a timely manner.

• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.

• Gather patient views and experiences to ensure the services provided reflect the needs of the population served.

• Review the systems and processes in the dispensary to ensure they are effective.
• Ensure there is leadership capacity to deliver all the improvements.
• Develop ways to monitor and improve patient satisfaction.
• Consolidate the complaints process and ensure learning from complaints are discussed and shared. Ensure trends are analysed and action is taken to improve the quality of care as a result.
• Formalise meetings with staff to support staff feedback and maintain records of discussions with actions agreed upon.

In addition the provider should:

• Review procedures for carrying out regular balance checks of controlled drugs

• Ensure safeguarding registers are updated and actions documented in regard to children who do not attend for hospital appointments.

• Ensure all staff have completed safeguarding training relevant to their role.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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

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 Sleaford Medical Group on 6 May 2015. Overall the practice is rated as good.

Specifically, we found the practice to be providing safe, effective, caring, responsive and well led services. It was also good for providing services for all the population groups.

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

• Staff were overwhelmingly positive about the new management structure. There was good evidence of team working. Motivation and enthusiasm was evident during the inspection.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. In the information from the January 2015 national GP survey both GP’s and nurses scored highly on satisfaction scores for listening to and giving patients enough time
• Patients said they did not find it easy to make an appointment with the same GP to ensure continuity of care. Urgent appointments were available on the same day.
• The practice had good facilities and was well 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 practice had a number of policies and procedures to govern activity, but some were overdue for review.

We saw an area of outstanding practice:

• The practice had identified the need for more reception staff, health care assistants and minor illness nurses and had recently employed these staff. They had also created a new role within the minor illness unit to accommodate specific minor illness home visits carried out by the practice. In order to facilitate this the practice had proactively employed a triage and minor illness nurse trainer on a three year contract. This was in order to train and provide on-going support to a combination of nine existing or newly employed practice nurses in triage and minor illness.

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

The provider should :-

• Ensure clinical audits are completed cycles to demonstrate improvements to patient outcomes.
• Ensure all staff have access to policies, procedures and guidance which are robust, reviewed and updated to enable them to carry out their role, for example, cold chain, infection prevention and control, legionella and COSHH.
• Have appropriate systems in place to ensure standards of cleanliness are maintained and to prevent the risks of infection by; having cleaning schedules in place, finalising the legionella risk assessment and continuing to address infection prevention and control issues (such as cleaning the ear syringing equipment in line with the practice policy.)
• Have a risk assessment in place to ensure the safe management of emergency
• medicines to be administered to patients on home visits.
• Ensure learning from complaints is shared with all staff.
• PPG minutes should be available in the practice and on the practice website.
• The practice should have practice meetings which are regular, structured and relevant to give all staff the opportunity to take part, where information is shared and lessons learnt. For example, significant events, complaints, risk management, infection control and NICE guidance. Meetings should be minuted in order to record summaries of topics discussed and actions to be taken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our previous inspection on 11 November 2013 we identified concerns that the practice had not got appropriate arrangements in place for the security of medicines.

We found that the practice did not have clear procedures for the reporting of medicine errors or systems in place to ensure that medicines were safely administered.

The practice did not have systems in place to keep their policies and procedures up to date.

We also found that the practice did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

We found that the practice did not have clear procedures for the reporting of significant adverse events or systems in place to ensure that lessons had been learnt and information had been disseminated to all the staff who worked at the practice.

We asked them to take action.

At this inspection we spoke with the practice manager, lead dispenser and a receptionist. We spoke with four patients and a representative from the patient participation group (PPG). The PPG is a group of patients who have volunteered to represent patients’ views and concerns and are seen as an effective way for patients and GP surgeries to work together to improve services and to promote health and improved quality of care.

Patients were happy with all aspects of the service the practice provided except getting through to the practice by telephone to make an appointment. Prior to this inspection we received information of concern regarding the appointment system and referral systems in place at the practice.

The practice had procedures for the reporting of medicine errors and systems in place to ensure that medicines were safely administered.

We found the practice had taken steps to carry out the required improvements since our last visit and there was now a system in place to ensure that all policies and procedures were accessible to staff.

The practice had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

The practice did not have effective systems in place assess and monitor the quality of the service provision.

People told us they were able to see the doctor of their choice. One person said, “My doctor is my doctor and you build up a relationship, continuity is important. You tend to get the doctor you want to see. If you speak to the receptionist they will sort it out for you.”

People told us the reception staff were responsive to their needs. One person told us they were, “Absolutely fine, friendly and helpful.” People we spoke with told us they were happy with the service they received and were confident in the clinician they saw. One person told us they had felt, “Really supported by the nurses.”

We saw systems ensured people received their medication when needed. One person said the staff who dispensed medication were, “A happy bunch-always smiling and ready to help.” Medication was safely obtained, stored and disposed of. However, systems for investigating medication errors were not always completed in a timely fashion.

We saw there was sufficient numbers of staff with the appropriate skills and knowledge to meet people’s needs.

The provider had systems in place to monitor the service people received. However systems for identifying risks and developing the service were not always completed in a timely fashion.