Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of Somerset Medical Centre on 21 July 2015, the practice was given an overall inadequate rating. Due to serious concerns about patient safety a decision was made to suspend the registration of the provider for a period of three months from 27 July 2015 to 27 October 2015. The provider appealed to a first-tier tribunal and a hearing was held on 01 October 2015. The appeal was dismissed by the tribunal upon agreement that we would re-inspect the practice on 14 October 2015 to assess if sufficient improvements had been made to allow the practice to re-open.

Following the inspection in October 2015 we found some improvements had been made however we still had concerns about the leadership of the practice and a decision was made to cancel the registration of the registered manager. The practice was placed in special measures and was found to be in breach of five regulations. Requirement notices were set for regulations 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008.

We then carried out an announced comprehensive inspection on 16 August 2016 to consider if all regulatory breaches in the previous

October 2015 inspections 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 the practice had a new leadership team in place who had worked with the Royal College of General Practitioners (RCGP) to make the necessary improvements to the service provided. We found significant improvements had been made. 

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.
• 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 facilities and was equipped to treat patients and meet their needs although the premises were in need of a general upgrade.
• There was a clear leadership structure and staff felt supported by management. The practice 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 should make improvement are:

• Continue to improve the identification of disease and the coding of patients on the Quality and Framework Outcomes (QOF) registers.
• Improve multidisciplinary team working to meet the needs of patients with complex conditions.
• Record do not attempt cardiopulmonary resuscitation decisions on care plans where appropriate.

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) 

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Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of Somerset Medical Centre on 21 July 2015, the practice was given an overall inadequate rating and due to serious concerns about patient safety a decision was made to suspend the registration of the provider for a period of three months from 27 July 2015 to 27 October 2015. The provider appealed to a first-tier tribunal and a hearing was held on 01 October 2015. The appeal was dismissed by the tribunal upon agreement that we would re-inspect the practice on 14 October 2015. During this inspection we found sufficient improvements had been made to lift the suspension however there were still serious concerns in relation to the management and leadership of the practice.

We carried out an announced comprehensive inspection at 09:30hrs on 14 October 2015. Overall the practice is rated as inadequate.

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

• There was a lack of effective leadership at the practice.

• Procedures had been reviewed to keep patients safe however further improvements were necessary in relation to significant event analysis and safeguarding children and adults.

• There was insufficient assurance to demonstrate people received effective care and treatment. For example clinical audit was not used to improve outcomes for patients, NICE guidance was not routinely shared and clinical staff had a limited understanding of the Mental Capacity Act 2005 and how to carry out mental capacity assessments.

• National patient survey data showed the practice scored below average in terms of access to appointments, access to a preferred GP and several other aspects of care.

The areas where the provider must make improvements are:

• Ensure effective leadership is in place to include oversight and understanding of all the systems in place to deliver a high standard of care to patients.

• Introduce procedures to ensure all clinicians are kept up to date with national guidance and guidelines and updates shared within the clinical team to improve whole practice care.

• Ensure audits of practice are undertaken, including completed clinical audit cycles to improve patient outcomes.

• Ensure all staff understand and implement the key principles of the Mental Capacity Act 2005 and Gillick competences.

• Ensure safeguarding policies contain up-to-date guidance.

• Develop a clear vision for the practice and a strategy to deliver it. Ensure it is shared with staff and staff know their responsibilities in relation to it.

• Ensure staff appraisals are carried out by staff who are competent to do so.

• Act on feedback from the national GP patient survey to ensure areas of poor performance are addressed.

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 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 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 by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. 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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Somerset Medical Centre on 21 July 2015. Overall the practice is rated as inadequate.

Specifically we found the practice inadequate for providing safe, effective, caring and well-led services and requires improvement for providing responsive 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 and medicine management.
• There was insufficient clinical staff to keep patients safe and inadequate clinical leadership.
• National patient survey data showed the practice scored below average in terms of access to appointments, access to a preferred GP and several other aspects of care.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

Importantly, the provider must:

• Ensure there is adequate clinical staff employed in the practice and with the appropriate skills to meet the needs of patients and there is adequate clinical leadership within the practice.
• Ensure staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform including providing clinical care and treatment in accordance with national guidance and guidelines.
• Review arrangements for storing and accessing emergency equipment / medicines and ensure regular checks are recorded. 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. Ensure vaccine fridge temperatures are checked daily and recorded.
• Implement robust procedures for identifying, reporting, taking appropriate action and sharing learning from significant events / incidents and ensure safeguarding procedures are robust.
• Introduce a detailed locum induction pack to ensure all locums have adequate information to carry out their roles safely.
• Ensure information received from other service providers is acted on in all instances and robust handover procedures are in place for staff to follow at the end of clinical sessions.
• Implement action plans to improve Quality and Outcomes Framework (QOF) performance and carry out clinical audit to drive improvement in patient outcomes.
• Develop a clear vision for the practice and a strategy to deliver it. Ensure it is shared with staff and staff know their responsibilities in relation to it.
• Ensure all of the practices’ policies and procedures are up to date, accurate and staff know where they are located and understand them.

In addition the provider should:

• Provide staff training in equality and diversity.
• Implement measures to improve patient satisfaction in relation to access to appointments / preferred GP, involvement in decisions about care and treatment, consultations with the GPs and nurses and being treated with care and concern by clinical staff.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. Somerset Medical Centre are not to carry out any regulated activities at the location for a period of three months.

On 21 July 2015 we served the practice a Section 31 of the Health and Social Care Act 2008 (“the Act”) notice to impose these conditions in relation to their registration as a service provider. This will be for a period of three months. We will inspect the practice again in three 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 spoke with five members of the Patient Participation Group, the practice manager, two GPs, one healthcare assistant, practice nurse, reception and administrative staff.

All the people we spoke with said they were very satisfied with the quality of care and treatment they received from the practice. People told us they were listened to, respected and that their privacy and dignity was maintained. They told us they were involved in decisions regarding their care and treatment and that any possible risks were explained. Comments we received from people included “I find the practice very good, if I did not I would not be here”, “the staff are very helpful, everybody here is very good, I would give them a rating of 100%”.

People who used the service were protected from the risk of abuse, because the provider had taken steps to identify the possibility of abuse and prevent abuse from happening.

Staff received appropriate professional development. People told us they had confidence in the knowledge and skills of the staff.

A complaints system was in place and people we spoke with were confident to raise any concerns they had.