A comprehensive inspection was carried out on 31 May 2017. The practice was rated as inadequate overall, and inadequate for providing safe, responsive and well led services and requires improvement for providing effective and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 28 July 2017 for regulation 17 (good governance). The practice was placed into special measures for six months. A focused inspection was carried out on 18 October 2017 to check on improvements detailed in the warning notice issued on 28 July 2017, following the inspection on 31 May 2017. We carried out an announced comprehensive inspection at Central Healthcare Centre on 29 January 2018. This inspection was undertaken following the period of special measures. At this inspection, the practice was rated as requires improvement for effective, responsive and well led services and was taken out of special measures. The full inspection reports on the May 2017, July 2017 and January 2018 inspections can be found by selecting the 'all reports' link for Central Healthcare Centre on our website at www.cqc.org.uk.

Central Healthcare Centre had merged with Gorleston Medical Centre on 1 October 2018 and were called The Beaches Medical Centre. However, they had not updated their CQC registration to reflect this and were still registered with CQC as Central Healthcare Centre at the time of this inspection. Some data in the evidence table related to Central Healthcare Centre and some to The Beaches Medical Centre. This was dependant on the date range of when the data was collected and the date of data publication. We carried out an announced comprehensive inspection at Central Healthcare Centre on 6 March 2019 to follow up on breaches of regulation identified at our previous inspection on 29 January 2018.

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 inadequate for all population groups. At this inspection we found:

• Improvements had been made to the practice’s quality and outcomes framework performance and exception reporting. Arrangements to review patients with long term conditions, who lived in care homes had improved.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

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

• The practice had 2,335 electronic letters, which had not been reviewed to see if any actions needed to be taken by the practice, or coded. The practice was aware of this and had taken some action to address this; with additional action taken following the inspection. We reviewed a sample of four letters and no action was needed.
• They had 333 patients whose notes had not been summarised. These dated to September 2018. The practice advised this had become an issue since the merger. Following the inspection, they commenced the outstanding summarising.
• Following our previous inspection, the practice had established and implemented a system to assure themselves of the competency of clinicians working in advanced roles. At this inspection, these formal, documented checks had not been completed for approximately five months. Non-medical prescribers had access to their peers and GPs and could obtain advice if needed. The system of auditing the work of non-clinical staff who reviewed patient correspondence and summarised was not being implemented. The practice was aware of this and planned to re-establish these systems.
• Disclosure and Barring Service (DBS) checks were not undertaken when required. Following the inspection, the practice completed a risk assessment and confirmed they were in the process of or had applied for the DBS checks.

We rated the practice as good for providing effective services, although we acknowledged that the backlog of unreviewed patient correspondence, could impact on the effectiveness of the care provided. We rated the population group people with long term conditions as requires improvement for providing effective services because:

• The practice had completed 29% of reviews of patients with a learning disability in the past 12 months. The practice was aware and advised that although they had identified a clinical and administration learning disability lead and met with the learning disability nurse in May 2018 to review their system, due to the workload associated with the merger, this work had not progressed. They had a 2019 action plan in place.

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

• The 2018 national GP patient survey (which related to Central Healthcare Centre), had lower than average results for treating patients with care and concern, listening to patients and for overall experience of the practice. The practice was not yet able to evidence if actions taken to improve these areas had been effective.

We rated the practice and all population groups as inadequate for providing responsive services because:

• Patients did not find it easy to make an appointment and urgent appointments were difficult to access.
• The practice had a backlog of 2,335 electronic letters which had not been reviewed to see if any actions needed to be taken by the practice, or coded.
• The 2018 national GP patient survey (which related to Central Healthcare Centre), had lower than average results for access. The practice had tried different ways to improve access but with limited success.
• Staff were not all aware of the ‘being responsive to patients’ suggestions’ leaflet which provided information on the complaints process for patients.
• These issues related to patients across all the population groups, which are therefore all rated inadequate.

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

• Leaders did not have the capacity to lead effectively. Some systems which had been established and implemented previously by the practice, were not being sustained at the time of this inspection, due to a lack of capacity.
• The practice had a formal process to assure themselves of the competency of staff employed in advanced clinical practice, however, this process had not been implemented for approximately five months. The practice was aware of this and planned to start implementing this process again.
• The system for reviewing patients’ correspondence was not effective. The practice had 2,335 electronic letters, which had not been reviewed to see if any actions needed to be taken by the practice, or coded. Following the inspection, the practice advised that four non-clinical staff were working to review the backlog of letters.
• The system for summarising patients’ notes was not effective. There was a backlog of patients notes which needed to be summarised. The practice advised the backlog was due to staff shortages and sickness, since they had merged. Following the inspection, they acted to start to complete the outstanding summarising.
• The system of auditing the work of non-clinical staff who reviewed patient correspondence and summarising was not being implemented. The practice was aware of this and planned to start implementing this process again.
• The practice had a mission statement and a practice development plan, but it was not supported by a vision, or values to provide high quality sustainable care.
• There were low levels of staff satisfaction, high levels of stress and work overload. Many staff did not feel supported by the practice, due to the pressure of work. They did not always feel able to raise concerns with management due to the pressure the management team were under.
• The practice had merged on 1 October 2018, but had not submitted the necessary statutory notifications and application to CQC to ensure their registration was current. Additional applications needed to be submitted to ensure the registration was accurate.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider

should

make improvements are:

• Formalise and update documentation relating to infection prevention and control.
• Continue to engage with the clinical commissioning group in areas where the practice are outliers for prescribing.
• Continue with the planned programme of clinical audits.
• Continue to provide appraisals for staff.
• Advise all staff of the ‘being responsive to patients’ suggestions’ leaflet, which provided information on the complaints process for patients.

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.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Central Healthcare Centre on 2 October 2014. The practice was rated good overall with good ratings for every domain.

A full comprehensive inspection was carried out on the 31 May 2017. The practice was rated as inadequate overall, and inadequate for providing safe, responsive and well led services and requires improvement for providing effective and caring services, and was placed in special measures. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 28 July 2017 for regulation 17 (good governance). The practice was placed into special measures for six months. The full inspection reports on the October 2014 and May 2017 inspections can be found by selecting the ‘all reports’ link for Central Healthcare Centre on our website at www.cqc.org.uk.

A focused inspection was carried out on 18 October 2017 to check on improvements detailed in the warning notice issued on 28 July 2017, following the inspection on 31 May 2017.

We carried out an announced comprehensive inspection at Central Healthcare Centre on 29 January 2018. This inspection was undertaken following the period of special measures. Overall, the practice is now rated as requires improvement. The practice is no longer in special measures.

The key questions are rated as:

Are services safe? good

Are services effective? requires improvement

Are services caring? good

Are services responsive? requires improvement

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 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

At this inspection we found:

• The practice had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the practice learned from them and improved their processes.
• The practice ensured that care and treatment was delivered according to evidence- based guidelines. Monitoring of the work undertaken by the advanced nurse practitioners was formalised and effective.
• The practice performance in relation to the Quality and Outcomes Framework for 2016/2017 was lower than the national averages. Data the practice shared with us for 2017/2018 showed there was an improvement but it was insufficient to assure that all patients would receive appropriate follow up in a timely manner.
• The practice had 94 patients on the practice learning disability register; 43 of these patients had received a health review since October 2017.
• The practice supported staff to undertake training and obtain additional qualifications. For example, training on atrial fibrillation, and asthma. One nurse was being supported to become an advanced nurse practitioner.
• Staff involved and treated patients with compassion, kindness, dignity and respect. All staff had received equality and diversity training.
• Patients we spoke with said they did not find it easy to make an appointment and that urgent appointments were difficult to access. The 2017 national GP patient survey had lower than average results relating to access to services. Although the results of a practice survey in November 2017 showed some improvement in relation to waiting time after arriving for their appointment and convenience of appointment time, they still had low results for access.
• Information on the complaints process was available for patients at the practice and on the practice’s website. There was an effective process for responding to, investigating and learning from complaints.
• The practice had worked hard to develop an overarching governance system which gave the management team an overview of the performance of the practice. For example, recruitment, training and appraisal. Actions from the health and safety risk assessment were monitored, although not all actions had been completed.
• There was no formalised strategy or business plan and, although there was a set of values, not all staff were aware of these.
• The practice had undertaken a staff survey in August 2017 and identified actions had been collated and discussed. However some of the staff we spoke with did not feel that concerns raised, would be acted upon. Some staff we spoke with did not feel supported by the practice, due to the pressure of work.
• The practice had an active patient participation group. They had held a coffee morning to promote the identification of carers and had planned a mental health and young people event in April. They also produced seasonal newsletters and had a social media page to promote practice information.

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

• Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

The areas where the provider should make improvements are:

• Continue to action the recommendations from the health and safety risk assessment.
• Continue to monitor the national GP patient survey data and continue to make changes to improve the experience of patients.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the 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 Central Healthcare Centre on 2 October 2014. The practice was rated good overall with good ratings for every domain.

A comprehensive inspection was carried out on the 31 May 2017. The practice was rated as inadequate overall, and inadequate for providing safe, responsive and well led services. The practice was rated as requires improvement for providing effective and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 28 July 2017 for regulation 17 (good governance). The practice was placed into special measures for six months The full inspection reports on the October 2014 and May 2017 inspections can be found by selecting the ‘all reports’ link for Central Healthcare Centre on our website at www.cqc.org.uk.

This inspection was to check on improvements detailed in the warning notice issued on 28 July 2017, following the inspection on 31 May 2017. This report only covers our findings in relation to those requirements.

Our key findings from this inspection were as follows:

• There was an effective system in place to support patients who take medicines that require monitoring.

• A process had been established to review and act on Medicines & Healthcare products Regulatory Agency (MHRA) alerts.

• There was an effective system in place for the management and coding of clinical letters.

• There was an overarching governance system in place which gave management an overview of the performance of the nursing team.

In addition the provider should:

• The provider should continue to monitor the newly implemented systems and processes to ensure improvements to quality and safety are made and monitored. For example, the management and monitoring of safe prescribing.

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 the Central Healthcare Centre on 31 May 2017. Central Healthcare Centre merged with a local practice, which was rated as requires improvement, in June 2016 and took on an extra 5,000 patients from a deprived area. Overall the practice is rated as inadequate.

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

• There was a system in place for reporting and recording significant events; however, the practice did not monitor trends in significant events.

• The governance framework was not always effective and did not assure us that risks to patients were always mitigated. For example, the immunisation of some clinical staff was unknown. The practice had a gym for patients use, but the risk assessment in place was not effective. There was no health and safety risk assessment in place and regular fire drills had not been undertaken.

• The system in place to deal with patient safety alerts needed to be improved. The alerts were sent to all GPs, but there was no system in place to monitor the actions taken in response to the alert.
• The practice had a medicine review system in place to support patients who take medicines that require monitoring. However, data demonstrated this system was not always effective.
• We found a significant number of clinical letters had not been coded. The practice reported that all letters had been reviewed by a clinician when they were received. The practice had recognised this and had put some systems in place to address it.
• Data from the Quality and Outcomes Framework showed patient outcomes in many areas were below national averages.
• Advanced nurse practitioners had limited clinical supervision with GPs and did not have one to one peer reviews, but did have group training for one hour per fortnight with a GP.
• Results from the national GP patient survey, published in July 2017, showed the practice was in line with or below local and national averages for many aspects of care. The practice was unaware of these results.
• Less than 1% of the practice list had been identified as carers.
• Information about services and how to complain was not readily available. Not all staff were informed of the outcome of complaints and there was no trend analysis of complaints.
• Patients we spoke with said they did not find it easy to make an appointment with a named GP and urgent appointments were difficult to book.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The governance arrangement for the oversight of the clinical teams was not effective and did not ensure cohesive working.

The areas where the provider must make improvements are:

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

• Ensure care and treatment is provided in a safe way to patients.

The areas where the practice should make improvements are:

• Continue to identify carers and consider the need for health checks and additional support for this patient group.

• Continue to embed systems for the coding of all clinical letters to ensure that an accurate, complete, and contemporaneous record is maintained for every patient.

• Conduct a trend analysis for significant events and complaints.

• Increase awareness of the GP patient survey and respond to the results as appropriate.

• Continue to embed systems to improve quality outcomes for patients.

• Consider the need to formalise the clinical supervision of the nursing staff from the GPs in order to enhance the support in place.

• Ensure the process for dealing with complaints is effective and learning outcomes are cascaded to all members of staff.

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 may take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This could lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. We have acknowledged in the report that the Practice has taken on another patient list in 2016, which had been rated as ‘Requires Improvement’, the provider is encouraged to make the necessary improvements and will be re-inspected within 6 months.

The service will be kept under review and if needed could be escalated to urgent enforcement action.

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 visited Central Surgery on the 2 October 2014 and carried out a comprehensive inspection.

The overall rating for this practice is good, with areas of outstanding for effective and responsive care.

Our key findings were as follows:

• Patients were satisfied with the service and felt they were treated with dignity, care and respect and involved in their care.
• There were systems in place to provide a safe, effective, caring and well run service.
• There was a good understanding of the needs of the practice population and services were offered to meet these.

We saw areas of outstanding practice including:

• The practice employed a nurse practitioner to manage and coordinate care for patients in care homes
• The practice employed a health care specialist with fitness training to support patients improve their quality of life.
• The practice provided a fully equipped gym to assist patients with their quality of life improvements.
• The practice employed a mental health counsellor to support patients who have mental health needs.
• The practice provided a care support worker to support patients, their families and their carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice