We carried out an announced comprehensive inspection at The Grange Family Health Centre on 4 April 2019 as part of our inspection programme.

The Grange Family Health Centre received a previous CQC inspection in January 2018. At that inspection, it received a rating of requires improvement for providing caring, responsive and well-led services and this led to an overall rating of requires improvement. We rated the practice as requires improvement for providing caring, responsive and well-led services because:

• Some practice systems needed strengthening, and assurances for clinicians working in an extended role required more oversight.
• Results from the national GP patient survey showed areas of lower than average patient satisfaction in areas relating to access, and experience during consultations.

The practice was rated as good for providing safe and effective services. The full comprehensive report (published April 2018) for this inspection can be found by selecting the ‘all reports’ link for The Grange Family Health Centre on our website at www.cqc.org.uk

At this inspection on 4 April 2019, we found that the provider had satisfactorily addressed most of the previously identified concerns. However, work was ongoing to address areas of lower levels of patient experience, particularly in respect of access to appointments. Therefore, the practice is rated as requires improvement for providing responsive services.

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 good overall but is rated as requires improvement for providing responsive services. As this impacts on all population groups, these have also been rated as requires improvement.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. We observed that there were improvements with regards to how patients could access care and treatment in a timely way, although further work was needed to address this effectively.
• The way the practice was led and managed promoted the delivery of good quality, person-centre care.

Whilst we found no breaches of regulations, the provider shoul

d:

• Continue to review patient feedback mechanisms, particularly in relation to access, and ensure sustainable improvements can be maintained.
• Ensure that all employees, including GPs, are subject to the same rigorous recruitment checks and records are held to evidence this has taken place.
• Maintain documented evidence of when fire drills have been undertaken.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall

.

At the previous Care Quality Commission (CQC) inspection in May 2017, the practice received an inadequate overall rating and was placed in special measures for a period of six months.

Our announced comprehensive inspection on 23 January 2018 was undertaken to ensure that improvements that had been made following our inspection in May 2017.

The inspection of The Grange Family Health Centre was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The Grange Family Health Centre is the name that has been registered with the CQC, but the management of the practice and the two branch sites is undertaken by Royal Primary Care. Royal Primary Care is owned, managed and accountable by Chesterfield Royal Hospital NHS Foundation Trust.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires improvement

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. We rated the practice as requires improvement for providing caring, responsive and well-led services. The concerns which led to these ratings apply across all the population groups we inspected. There were however, examples of good practice.

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

At this inspection we found:

• Significant work had been undertaken by Royal Primary Care to address the findings of our initial inspection in May 2017. It was acknowledged that some issues were part of a longer-term approach in order to impact positively on quality measures and patient experience.
• The practice had completed actions identified at the previous inspection and had made considerable improvements. However, we found some areas where systems and processes needed additional focus for example: improving patient experience in terms of telephone access; the management of uncollected prescriptions; regular health checks for patients with a learning disability; the identification and support for carers; and improving patient satisfaction results.
• Royal Primary Care had a clear strategy and had developed visions and values which had been communicated with the practice team to ensure individuals understood their contribution to this.
• The recent appointment of a lead GP helped to drive clinical improvements, and provided clinical leadership for the salaried GPs.
• We saw notable progress had been achieved with regards to the review and interpretation of NICE guidance, and the management of alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
• The practice provided evidence of a quality improvement programme. This included audits produced by both GPs and nurses and we saw how these were being used to drive improvements in patient care.
• The practice encouraged and supported staff to report incidents. When incidents did happen, the practice learned from them and improved their processes.
• The practice team worked in partnership with community based teams to deliver effective care for their patients. Regular meetings were held with health and social care representatives to plan and review the care of the practice’s most vulnerable patients.
• Royal Primary Care had undertaken a successful recruitment campaign and used innovative means to approach new candidates including social media and an open day. This had led to recruitment to all but one new vacancy within the administrative team, and two long standing salaried GP posts.
• Continuous learning and improvement was encouraged at all levels within the practice. Staff training records showed that most essential training had been completed, and regular appraisals helped to encourage the development of the practice team.
• Results from the latest national GP patient survey published in July 2017 showed that the practice had performed below local and national averages in the majority of the questions about patient experience. However, these results related to the period January-February 2017 before our initial inspection took place, and patients told us that their experience was improving. The practice provided us with results from their own internal survey undertaken between October to December 2017, which showed that patient feedback was improving. 
• Patients were mostly negative regarding access to GP appointments. However, improvements to telephone access had been achieved since our previous inspection, and the practice provided updates on progress to their patients. Further work was still required to improve patient experience in line with local averages. 
• The practice had a complaints policy and procedure although some information required updating to be compliant with recognised guidance and contractual obligations for GPs in England. The complaints information provided was not consistent across the website, patient information leaflet, and patient response letters. 
• The practice had identified almost 1.5% of their patients as being carers. There was limited evidence of measures being employed to support and review carers’ needs.

Importantly, the provider must make improvements to the following areas of practice:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For details, please refer to the requirement notice at the end of this report.

The areas where the provider should make improvements are:

• Review chaperone arrangements to ensure patients are aware of and understand this service, and reinforce with staff which staff are able to operate as chaperones.
• Review the procedure and frequency for monitoring uncollected prescriptions from reception.
• Follow up on the learning disability patient register review with an improved uptake of annual reviews.
• Consider approach to carers of all patients, to build on the work being undertaken with carers of patients with dementia.

At this inspection we found the providers had significantly strengthened their leadership and management and had taken a proactive team approach towards making and sustaining improvements in quality. I am therefore 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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Grange Family Health Centre on 24 May 2017. This was the first inspection of Royal Primary Care at this location as the new provider of this service. Royal Primary Care is owned, managed and accountable to Chesterfield Royal Hospital NHS Foundation Trust. Overall the practice is rated as inadequate.

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

• Royal Primary Care inherited significant issues which it had been working hard to address since taking over the practice’s management in 2015. This entailed a major change programme including a restructure of the workforce alongside integration with the trust’s infrastructure and ways of working.
• Royal Primary Care had completed the majority of the change programme at the time of our inspection, but recognised they still required time to fully embed new arrangements and to assess the impact they achieved for patients, staff and the practice culture.
• To respond to the long-standing difficulties of national GP recruitment, the trust had re-designed a skill mix to best meet the needs of the practice’s registered patients. As well as consulting with a GP, patients had the choice to see either a nurse practitioner, pharmacist, mental health nurse or physiotherapist at the practice.
• Despite the varied skill mix, GP capacity remained an issue, and we saw that the turnover of employed GPs remained comparatively high. The trust was actively trying to recruit more medical capacity.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Learning was applied when any adverse incident or near miss took place to prevent similar occurrences in the future.
• The provider had some systems to minimise risks to patient’s safety. When risks were identified, they were captured on Royal Primary Care’s risk register which was monitored at the Performance and Quality Board. Any significant risks that were identified were escalated to the trust’s High Level Risk Register for inclusion and oversight by the Trust Board. However, on the day of our inspection, we observed that risks were not always identified including the prompt actioning of test results and compliance with safety alerts. Staff were mostly aware of current evidence based guidance. However, we were told that staff mostly reviewed guidance on an individual basis, and we saw limited evidence of this being considered collectively as a team.
• Although the practice had achieved good outcomes for the Quality and Outcomes Framework (QOF), levels of exception reporting were high and exceeded local and national averages. Exception reporting is the removal of patients from QOF calculations due, for example, to patients being unable to attend a review of their condition and health needs.
• Practice staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. The trust was in the process of completing a comprehensive competency based training package for a number of newly recruited administration and reception staff.
• Patients said they did not find it easy to make an appointment by telephone. This was a long standing issue which the trust were fully aware of, and a procurement exercise for a new telephone system was due to commence imminently.
• Results from the national GP patient survey showed the practice performed below local and national averages when patients were asked if they were treated with compassion, dignity and respect, and involved decisions about their care and treatment. However, we saw that this was improving as patients became more confident in the new structure.
• Feedback from staff in care homes indicated that there had been problems with service continuity, and the level of responsiveness provided to requests for a visit. However, care home staff told us that the service was beginning to improve.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• There was a clear leadership structure and most staff informed us that they felt supported by managers.
• We highlighted a number of serious concerns during our inspection, including the timely actioning of test results, responding effectively to medicines alerts, and the management of incoming correspondence. The trust took immediate action to address those issues that had the potential to impact upon patient safety. The trust provided us with an extensive action plan in response to our feedback on the day of the inspection, and demonstrated that this was being monitored at the highest level within the trust.

The areas where the provider must make improvement are:

Ensure care and treatment is provided in a safe way to patients including:

• Ensure safe systems are in place to review the workload of GPs such as a buddying arrangements to oversee the management of incoming correspondence.
• Strengthen systems to ensure safe prescribing for patients in respect of safety alerts, test results, and for those taking high risk medicines. The practice must also implement a robust procedure for the distribution of blank prescriptions across the three sites.
• Ensure there is adequate medical cover provided across the three sites.
• Implement a documented cleaning schedule for medical equipment in accordance with manufacturer’s instructions.

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

• Ensure all new and updated NICE guidance is reviewed and documented through clinical meetings to ensure a clear record is maintained of any agreed actions.
• Carry out a defined programme of quality improvement activity.
• Devise a protocol for the management of safety alerts and provide a clear audit trail of actions taken in response to each alert received.
• Ensure the incident reporting form includes timescales to complete actions, and includes details of when these have been fully completed

The areas where the provider should make improvement are:

• Continue to review and improve processes for making appointments.
• Review input to care homes to deliver a more responsive service to meet patients’ needs.
• Maintain accurate minutes of meetings and ensure these are made accessible for appropriate staff to view.
• Review the business continuity plan to include an up-to-date staff contact list is available.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six 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