We previously carried out an announced comprehensive inspection at The Haymarket Health Centre on 11 January 2017. The overall rating for the practice was inadequate with inadequate for providing safe and well-led services, and requires improvement for providing effective, caring and responsive services. As a result, the service was placed into special measures and we issued a warning notice in relation to a breach in Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014: Good

Governance. We undertook an announced focused inspection on 3 July 2017 to follow up on the warning notice. We found that the provider had met the legal requirements of the warning notice. Following a period of special measures, we carried out an announced comprehensive inspection on 28 September 2017. Overall the practice was rated as good with requires improvement in providing responsive services and taken out of special measures. All of these reports can be found by selecting the ‘all reports’ link for The Haymarket Health Centre on our website at www.cqc.org.uk.

This inspection was an announced desk-based inspection carried out on 4 September 2018 to confirm that the practice had implemented recommendations identified in our previous inspection on 28 September 2017. This report covers our findings in relation to those requirements.

Overall the practice is now rated as good and good for providing responsive services.

Our key findings were as follows:

• The practice had carried out an extensive analysis of calls made to the practice. Systems and processes to improve patient telephone access to appointments had been established however national data showed that patient satisfaction remained low.
• Information about the practice’s complaints procedure was readily accessible to patients.

Additional improvements had also been made since our last inspection;

• There was a system in place to regularly analyse significant events to identify any common trends, maximise learning and help mitigate further errors.
• Visitors to the practice were briefed on the fire safety procedures and systems were in place to monitor and prevent obstructions to fire doors.

We saw one area of outstanding practice:

• To support patients who lived in the Longton area to access appointments at the practice’s central access hub on Saturday mornings, the provider had sub-contracted a shuttle coach service, free of charge, for these patients.

In addition the provider should:

• Consider additional ways of raising patient awareness of the types of appointments available and how patients are signposted to the most effective service to meet their needs.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at The Haymarket Health Centre on 11 January 2017. The overall rating for the practice was inadequate with inadequate ratings for providing safe and well-led services, and requires improvement ratings for providing effective, caring and responsive services. As a result, the service was placed into special measures. We found two breaches of legal requirements and as a result we issued a warning notice in relation to:

• Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Good Governance.

We also issued a requirement notice in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 – Safe Care and Treatment.

We undertook an announced focused inspection on 3 July 2017 to follow up on the warning notice. We found that the provider had met the legal requirements in relation to Regulation 17.

The full comprehensive report on the January 2017 inspection and the report on the July 2017 focused inspection can be found by selecting the ‘all reports’ link for The Haymarket Health Centre on our website at www.cqc.org.uk.

This inspection was undertaken following a period of special measures and was an announced comprehensive inspection on 28 September 2017. Overall the practice is now rated as Good.

Our key findings were as follows:

• Staff felt able and were encouraged to raise events and demonstrated a clear understanding of the procedure and understood their responsibilities to report incidents and near misses. Events were recorded, investigated and shared but did not always result in learning and quality improvement. A regular analysis of events had not been carried out to identity common trends.

• Systems and processes to safeguard patients had improved. Staff were aware of how to raise a safeguarding concern, had received training relevant to their role, and had access to internal leads and contacts for external safeguarding agencies.

• Following the recruitment of a practice pharmacist, an effective system had been introduced to log, review, discuss and act on external alerts, such as the Medicines and Healthcare products Regulatory Agency (MHRA) alerts that may affect patient safety.

• There were systems in place for the monitoring and prescribing of high risk medicines.

• There were systems in place for identifying, assessing and mitigating most risks to the health and safety of patients and staff. However, some health and safety aspects required improved oversight.

• The practice used innovative methods to improve patient outcomes. For example the practice had a community assessment team that visited patients with complex health and social support needs in their own homes. They carried out holistic assessments, made referrals and signposted patients to other agencies such as befriending and bereavement services where appropriate.

• 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 partners had reviewed and increased its workforce. They had employed additional clinicians with a varied skill mix to help meet the health and social needs of patients and the demand for access to appointments. A dedicated patient contact call centre had been opened to improve patient access across all of the provider’s services and to ensure patients were signposted to the appropriate clinician. However, feedback we gained from patients showed they continued to experience difficulty getting through to the practice by telephone and obtaining appointments. Results from the national GP patient survey supported these findings.

• A clear leadership structure had been developed and implemented. Key roles and responsibilities had been developed across the team. Staff told us they felt supported by the partners and management team and considered significant improvements had been implemented since the last comprehensive inspection.

• The partners and management team demonstrated oversight and understanding of the practice. They were aware of the continued improvements required to improve patient outcomes and the quality of the service.

• Results from the national GP patient survey published in July 2017 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

• Information about services and how to complain was available but not readily accessible.

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

• The practice had an active patient participation group in place to support patient feedback.

However, there were also areas of practice where the provider should make improvements.

• Establish effective systems and processes to improve patient access in line with patient feedback.

• Carry out a regular analysis of significant events to identify any common trends, maximise learning and help mitigate further errors.

• Ensure visitors to the practice are briefed on the fire safety procedures and at all times ensure fire doors are not obstructed.

• Ensure that information about the practice’s complaints procedure is readily accessible to 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 of The Haymarket Health Centre on 11 January 2017. Breaches of legal requirements were found and a warning notice was served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good Governance. A Requirement notice was served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe Care and Treatment. We rated the service overall as inadequate and placed the service into special measures to give people who use the service the reassurance that the care they get should improve. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Haymarket Health Centre on our website at www.cqc.org.uk.

We undertook a focused follow up inspection on 3 July 2017 to check that the practice had taken urgent action to ensure they met the legal requirements of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good Governance. This report only covers our findings in relation to the warning notice. A follow up inspection will be carried out to check that the practice has followed their action plan for the requirement notice and to confirm they have met legal requirements.

Our key findings were as follows:

• The practice had responded positively to the warning notice and had addressed issues previously identified in the warning notice.
• The practice had completed 13 clinical audits to include two full cycle audits since our last inspection which demonstrated improved outcomes to patients.
• The culture of reporting significant events had improved across the practice. A template for recording significant events had been developed and incidents had been recorded, investigated and shared. Staff were encouraged and were aware of how to raise a significant event.
• A protocol had been developed and implemented for the management of laboratory results such as bloods and urine.
• Additional clinical staff had been appointed to meet patient demand for access to appointments. The practice were encouraging patients to book on line and had recently opened a new patient access line managed by a dedicated patient contact call centre. This was to improve patient access and ensure patients were appropriately signposted to the appropriate clinician. However, some patients told us they were still experiencing difficulty getting through to the practice by telephone and obtaining appointments, particularly on a Saturday.
• Systems and processes to safeguard patients had improved. Staff were aware of how to raise a safeguarding concern, had received training and had access to internal leads. The practice were re-establishing links with external agencies such as the health visitor and meetings had been held.
• All staff had received chaperone training and were aware of the correct procedure to follow if they were required to chaperone. A chaperone policy and template had been developed and was accessible to staff to record patient requests for a chaperone.
• Clinical leadership and structure had been developed and implemented. Key roles and responsibilities had been developed across the team. Staff felt supported by the management team, were aware of the leadership structure and considered communication had improved. Staff had received an appraisal of their work.
• The partners demonstrated oversight and understanding of the practice. They were aware of the continued improvements required to improve patient outcomes, staff culture and the quality of the service.
• Governance arrangements had improved with the implementation of clinical meetings, improved communication, an increase in staffing in addition to a new management team and change of clinical system.
• There was a formal system in place to log, review, discuss and act on external alerts, such as the Medicines and Healthcare products Regulatory Agency (MHRA) alerts that may affect patient safety.
• The provider had reviewed the arrangements for medicines carried in GP bags for home visits. A risk assessment had been completed and a decision made not to carry any emergency medicines on GP home visits. However, the risk assessment did not consider all eventualities of how risk was mitigated for each individual condition.

However, there is an area of practice where the provider needs to make improvements.

The provider should:

• Review the method of communication used for advising patients to have a follow up blood test in relation to the results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Haymarket Health Centre on 11 January 2017. Overall the practice is rated as inadequate.

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

• Staff did not sufficiently understand their responsibilities to raise concerns, and to report incidents and near misses. We found that there was insufficient reporting of significant events and that some staff were unaware of the procedure.
• Risks to patients were not assessed and well managed. We found that The Medicines and Healthcare products Regulatory Agency (MHRA) drug safety updates had not been actioned.
• The majority of patients said they were treated with compassion, dignity and respect.
• There was not a clear leadership structure as the practice had gone through a period of unsettlement due to GPs leaving and a problem with recruitment of new GPs. The new leadership structure was very new and not yet embedded. The practice was aware of this and had implemented measures to address it, including requesting support from NHS England.

• Appointment systems were not working well so patients did not receive timely care when they needed it. Patients said they found it difficult to make an appointment with a GP and on the day of the inspection there were insufficient appointments to meet patients’ needs.

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

• Information about services and how to complain was available and easy to understand.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Introduce processes for reporting, recording, acting on and monitoring significant events, incidents, Medicines and Healthcare products Regulatory Agency (MHRA) drug safety updates and near misses in order to prevent avoidable harm to patients.

• Introduce a procedure to ensure that all medicines, including emergency medicines in the GP’s bag, are not out of date to prevent patients from receiving unsafe care or treatment.

• Carry out quality improvement activity including re-audits to ensure improvements have been achieved.

• Introduce safeguarding meetings in partnership with other relevant bodies to regularly review outcomes for patients using the service.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Clarify the leadership structure and ensure there is leadership capacity and good governance to deliver all improvements.

• Review the training of chaperones to ensure that they perform the duty correctly and keep patients safe.

In addition the provider should:

• Improve processes for making appointments.

• Increase the identification and support to carers on the practice list.

• Ensure whole team meetings and sharing of information with staff are embedded in practice.

• Ensure that all staff have an annual appraisal.

I am placing the service into 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 vary the provider’s registration 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