Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement.

We carried out an announced comprehensive inspection at Stockwell Lodge Medical Centre on 18 May 2017. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. A warning notice was served in relation to breaches identified under Regulation 12: Safe Care and Treatment. We completed an announced focussed inspection on 3 August 2017 to check on the areas identified in the warning notice and found that sufficient improvements had been made regarding these. The full comprehensive report and focussed reports of the May and August 2017 inspections can be found by selecting the ‘all reports’ link for Stockwell Lodge Medical Centre on our website at www.cqc.org.uk.

This announced comprehensive inspection on 18 January 2018 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

At this inspection we found:

• Processes were in place to keep patients safe. For example, the practice had effective systems for the monitoring of medicines and infection.

• We found the practice to be visibly clean on the day of the inspection and that our previous concerns identified through infection control audits had been completed or risk assessed.

• There was a system in place for reporting and recording significant events. Some formal complaints which were recorded should have been considered as significant events.

• We saw evidence that information and learning was disseminated to all staff.

• Staff were aware of current evidence based clinical guidance and one of the GP’s was the lead for this and discussions were recorded in clinical meetings.

• The practice staff were aware of their responsibilities regarding child and adult safeguarding with good signposting throughout the practice. All staff had undergone safeguarding training.

• Results from the Quality Outcome Framework (QoF) showed patient outcomes were comparable to the local and national averages.

• Audits had been carried out that were driving improvements in patient outcomes.

• National GP patient survey data published in July 2017 remained lower than local and national averages. However the practice had an action plan in place and were working to improve this.

• Comment cards completed by patients told us they felt they were treated with compassion, dignity and respect. However five of the 19 comment cards completed told us that they experienced difficulties in getting an appointment.

• The practice had clear leadership structure and designated lead roles in key areas.

• Formal governance arrangements were in place with policies and procedures stored on the practice intranet.

• Staff were aware of how the appointment system worked and had a comprehensive understanding of the appointments system, in particular with relation to access to emergency appointments.

• We noted that since our last inspection, the baby changing unit had been replaced and was safe to use and of a material that aids cleaning and hygiene.

• Complaints had been received and acknowledged, however there was no clear evidence or process to show actions and investigations in place for seven of those we viewed.

Importantly, the provider must:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

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

This service was placed in special measures in May 2017. Following inspection carried out January 2018, whilst some improvements have been made there remains a rating of inadequate for providing a responsive service. Therefore the service will be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we may 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 focused inspection on 3 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 May 2017.

This inspection was undertaken to follow up on a Warning Notice we issued to the provider and the registered manager in relation to:

• Regulation 12; Safe Care and Treatment.

The practice received an overall rating of inadequate following our inspection on 18 May 2017 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the report.

We issued a warning notice and this report only covers our findings in relation to the areas identified in the warning notice as inadequate during our inspection in May 2017. You can read the full report from our last comprehensive inspection in May 2017, by selecting the 'all reports' link for Stockwell Lodge Medical Centre on our website at www.cqc.org.uk.

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

• The practice had complied with the warning notice we issued and had taken the action required to comply with legal requirements.
• The practice had made improvements to the system for the management of patients receiving medicines that require monitoring, including high risk medicines and an effective process for clinical documentation.
• The practice had improved the standards of cleanliness and hygiene at the practice. There were cleaning schedules and monitoring systems in place.
• Infection prevention control (IPC) audits had been carried out and action plans were being developed by the practice IPC nurse with support from the East and North Hertfordshire Clinical Commissioning Group (CCG) lead.
• Lead members of staff with IPC responsibilities had undergone appropriate training for the role.
• Health and safety risk assessments had been undertaken in June 2017 and we saw evidence of action plans for both general health and safety throughout the practice including legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings) with required testing measures in place.
• An electrical wiring test had taken place and we saw evidence of a five year electrical wiring certificate dated June 2017.

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 Stockwell Lodge Medical Centre on 18 May 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 systems and processes were not in place to keep them safe. For example, the practice had did not have systems in place for the monitoring of medicines and infection prevention control.

• We found the condition of the practice to be poor and the practice had not maintained appropriate levels of cleanliness and identified concerns had not been addressed in relation to infection control.

• There was a system in place for reporting and recording significant events. However we did not see evidence that information and learning was disseminated to all staff.
• Staff were aware of current evidence based clinical guidance however we saw little evidence of it being followed.

• The practice staff were aware of their responsibilities regarding child & adult safeguarding with good signposting throughout the practice. Whilst the majority of staff had undergone safeguarding training we saw that there were gaps in safeguarding training in particular one member of clinical staff had not received formal training.

• Results from the Quality Outcome Framework (QoF) showed patient outcomes were comparable to the local and national averages. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.

• National GP patient survey data published July 2016 was considerably lower than local and national averages. Information received from the East and North Herts Clinical Commissioning Group (CCG) identified that the practice was one of the lowest scoring practices nationally.

• The majority of patients we spoke to said they were treated with compassion, dignity and respect. However patients consistently told us that they experienced difficulties in getting an appointment and they felt the condition of the premises was poor.

• The practice had no clear leadership structure and designated lead roles in key areas were ineffective. There was a lack of adequate formal governance arrangements in place, for example staff were unaware of where to access policies and procedures.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients, for example the safe prescribing and monitoring of medicines, appropriate management and monitoring of infection prevention control and maintenance of equipment.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, ensure systems or processes assess, monitor and improve the quality and safety of the serves provided.

The areas where the provider should make improvement are:

• Ensure monitoring and improvement to national GP patient survey results for example, patient experience and access to appointments.

• Ensure that all staff undertake training on the appointment system and have a comprehensive understanding of the appointments system, in particular with relation to access to emergency appointments.

• Ensure the baby changing unit is safe to use and is of a material that aids cleaning and hygiene.

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.

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 Stockwell Lodge Medical Centre on 4 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the each of the six population groups we looked at. It required improvement for providing safe services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and infection control.
• Data showed patient outcomes were average for the locality. We saw no evidence that clinical audits had been carried out to improve patient outcomes.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, but some of these had not been reviewed.

The areas where the provider must make improvements are:

• Ensure that all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess whether a DBS check is required.

In addition the provider should:

• Carry out infection control audits periodically.
• Implement a programme of clinical audits to evaluate and improve the quality of services provided.
• Maintain accurate and complete training records.
• Support staff through regular, scheduled appraisals relevant to the work they perform.
• Implement a system to ensure that blank prescriptions are tracked through the practice and kept secure at all times, as required under the NHS Protect Guidance, August 2013.
• Ensure all out of date policies and procedures are reviewed and up to date.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

When we previously inspected Stockwell Lodge Medical centre on 18 December 2013 we found that the provider was not compliant with a number of the essential standards. The provider wrote to us and said they would be compliant by the end of May 2014.

When we inspected again on 4 July 2014, we found that improvements had been made and the provider was compliant with those standards.

Patients’ privacy and dignity was preserved because there were arrangements in place to ensure they could speak confidentially to reception staff. The patient forum (a group of lay people who represent the views of patients) had been involved in regular discussions about the way the telephone triage system was evolving.

The provider had employed a full time infection control lead and an additional member of staff as premises manager. This ensured that the practice infection control policy was reviewed and applied and that the effectiveness of the practice cleaning arrangements was monitored. Environmental features we noted at our previous inspection that presented an infection risk had been rectified.

Improvements had been made to the arrangements for recording and storage of medicine so that medicines were kept securely and their expiry dates were monitored. A safeguarding lead had been identified and this was supported by safeguarding training for all staff to the level appropriate to their role.

The provider had an effective system to regularly assess and monitor the quality of service patients received. Regular meeting were also scheduled to communicate this to all staff.

Patients' privacy, dignity and independence were not always respected. We noted that the main reception was very open and offered patients minimal privacy when speaking with staff at reception.

We noted that patients were unable to book appointments directly with the practice and had to wait to be triaged on the telephone by a practice GP, who decided if the patient needed an appointment to see a GP.

One patient said, “I’ve got no complaints about anyone. The doctors are ok.”

Staff had access to appropriate emergency equipment within all areas of the practice.

We found the minor surgery room and consultation rooms had not been cleaned thoroughly. This meant the service had not fully managed the risk of infection.

All the medicines we checked were within their expiry dates. However; we found that medicines were not always kept safely or secured in locked cupboards.

We found that most staff had completed appraisals within the last year. One staff member said, “I feel well supported by the other staff.”

The practice was not monitoring and assessing the quality of services provided on a regular basis. The practice had not learnt lessons and implemented identified remedial actions resulting from significant events.