We carried out an announced comprehensive inspection at The Palms Medical Centre on 9 January 2019 as part of our inspection programme.

At the last inspection in January 2018 we rated the practice as requires improvement for providing responsive and well-led services because:

• Patient satisfaction at getting through to the practice by telephone was significantly below the national average.
• The practice was not sufficiently proactive in identifying risks. This was evidence through the lack of a system to ensure that temporary nursing staff at the practice were working appropriately under patient group directions
• The cervical screening failsafe system had lapsed in the absence of a permanent practice nurse.
• The practice did not have a comprehensive strategy to encourage the uptake of cervical screening except for contacting women by text messaging and reminding women when they attended the practice for other reasons.

At this inspection, we found that the provider had satisfactorily addressed these areas except for attaining increased patient satisfaction levels as seen by some of the low scores achieved by the practice in the last published National GP Patient Survey.

We based our judgement of the quality of care at this service is on a combination of:

• What we found when we inspected
• Information from our ongoing monitoring of data about services
• Information from the provider, patients the public and other organisations.

We have rated this practice as good overall, with key question responsive remaining as requires improvement.

We rated the practice as good for providing safe services because:-

• The practice had systems and processes in place to keep patients safe.
• Lessons were learned and improvements were made when things went wrong.
• The practice could demonstrate that had risk assessment in place in relation to safety issues

We rated the practice as good for providing effective services overall and across all the population groups because:-

• We saw that clinical staff assessed patient needs and delivered care and treatment in line with current legislation.
• The practice conducted quality improvement activities to help monitor the care and treatment provided.
• Clinical staff had the relevant skill, knowledge and experience to carry out their role.

We rated the practice as good for providing caring services because:-

• The practice gave timely support and information to patients.
• The practice respected patient’s privacy and dignity.
• The had improved their knowledge regarding the numbers of carers within the practice. Staff were active in identifying carers.

We rated the practice as requires improvement for responsive services overall and across all the population groups because:-

• The practice continued to achieve low patient satisfaction levels with regards to patients accessing the surgery by telephone as shown in the latest published National GP Patient Survey results.
• Recent reviews on the NHS page for the practice were mixed with one of the recurring themes being access to the practice by phone and the attitude of some members of staff.
• Complaints were handled in line with recognised guidance. The practice learned lessons and acted to improve services as a result of complaints received.

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

• The practice leaders had a vision and strategy for delivering quality care.
• Practice leaders looked after the safety and well-being of all staff at the practice.
• There was clear lines of responsibility, roles and systems to support good governance and management.

The areas where the provider must make improvements are:-

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

The areas where the provider should make improvements are:-

• Review the practice current approach to following up notifications of failed attendance of children’s appointments within secondary care.
• Regularly review that safety and medicine alerts received in the practice where there is a requirement to action, have been actioned.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The practice was previously inspected on 13 June 2017. At that inspection the rating for the practice was requires improvement overall. Following the inspection the practice we issued a warning notice in relation to the support and oversight of the health care assistant. The full comprehensive report can be found by selecting The Palms Medical Cetre ‘all reports’ link on our website at www.cqc.org.uk.

This inspection was undertaken to check that the practice was now compliant with regulations and was an announced comprehensive inspection carried out on 31 January 2018. At this inspection we saw improvements and the practice had made progress in addressing our concerns. The practice remains rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

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 clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• Care and treatment was delivered according to evidence-based guidelines. The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
• The practice encouraged healthier lifestyles and preventative care. However, practice coverage for cervical screening remained below average and the national target of 80%.
• Staff involved and treated patients with compassion, kindness, dignity and respect. The practice had increased the number of patients it had identified who were carers and could provide relevant advice and support.
• Patient rate of satisfaction was below the national average for the ease of obtaining an appointment with scores being particularly low for ease of getting through to the practice by telephone. This had not improved since our previous inspection although the practice had taken some actions designed to improve accessibility.
• The practice had a clear strategy for its longer term development and sustainability. For example it was in the process of expanding the permanent clinical staff team and had switched to a new electronic record system with improved functionality.

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.

The areas where the provider should make improvements are:

• Review its approach to cervical screening with the aim of improving uptake and coverage.
• Review the accessibility of the service with the aim of improving patient experience and meeting patients’ need to access to the practice, including by telephone.

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 Palms Medical Centre on 17 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for The Palms Medical Centre on our website at www.cqc.org.uk.

This comprehensive announced follow up inspection was undertaken on 13 June 2017. We found that some improvements had been made since the previous inspection. However we also identified some additional concerns. Overall the practice remains rated as requires improvement.

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

• There was an effective system in place for reporting, recording and learning from significant events and other incidents.
• The practice was not proactively identifying and managing all risks for example, in relation to medicines management.
• The GPs assessed patients’ needs and could demonstrate that care was being delivered in line with current evidence based guidance. However, care planning was underdeveloped and was an area for improvement.
• The practice was able to demonstrate that most staff had the skills, knowledge and support to deliver effective care and treatment. However, the practice had not put in place sufficient arrangements to support one staff member to ensure they were always acting within their clinical competencies and in line with good practice.

• Patients’ feedback was positive about the quality of consultations at the practice. The practice scored well on the national GP patient survey for these aspects of care.

• The practice had taken some action to improve access to the service for example offering more appointments. However, patient feedback on the experience of accessing the practice by telephone remained mixed and the practice scored significantly below average on the national GP patient survey in this area.
• The practice had taken recent action to improve cervical screening uptake but this had not yet had a meaningful impact on practice performance which remained below average.
• Patients could consult a male or female GP and a translation service was available. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear and stable leadership structure and staff said they were well supported. However the practice partners took a reactive approach to some important aspects of governance and this required improvement.
• Information about services and how to complain was available at the practice and easy to understand.

The areas where the practice must make improvement are:

• The practice must ensure that persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

• The practice must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This includes acting on feedback from patients, staff members and relevant external bodies.

The areas where the provider should make improvements are:

• The practice should review its appointment and telephone system to ensure the service is accessible to patients.
• The practice should review its systems and processes for managing medicines, for example properly documenting medicines reviews in care plans.
• The practice should develop a clinical audit programme that is shaped by practice priorities and routinely includes completed audit second stage cycles to ensure that improvements are sustained.
• Care plans should include sufficient detail to enable the coordinated delivery of care to patients with complex needs and those receiving palliative care.
• The practice should continue to focus on increasing cervical screening uptake rates.
• The practice should continue to identify patients who are carers and respond to their needs.

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 Palms Medical Centre on 17 March 2016. Overall the practice is rated as requires improvement. 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. The provider was aware of and complied with the requirements of the duty of candour.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment and had expanded the range of services available to patients.
• Patients said they were treated well at the practice and we received positive feedback about the quality of consultations at the practice. The practice scored well on the national GP patient survey for these aspects of care.
• Information about services and how to complain was available at the practice and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns and other forms of patient feedback.
• Patient feedback about accessing the practice by telephone was more negative. The practice scored in the bottom 5% of all practices in England on the national GP patient survey for this aspect of the service.
• Patients could consult a male or female GP and a translation service was available. Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The practice provided clinics for patients over 75, patients with diabetes, joint injections and fitted intrauterine devices (IUDs).
• There was a clear leadership structure, an open culture and staff said they were well supported. The practice proactively sought feedback from staff and patients, which it acted on.
• The practice was a training and teaching practice.

The areas where the practice must make improvement are:

• The practice must investigate whether it is currently providing reasonable telephone access to the service and make further improvements as required.

The areas where the practice should make improvement are:

• The practice should continue to monitor and improve its performance in relation to the management of diabetes and the uptake of cervical screening among the eligible population.
• The practice should assess its longer term clinical capacity given the recent increase in patient numbers.
• The practice should continue to increase the number of identified carers on its register to ensure their needs are met.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

People who used the service understood the care and treatment that was being provided for them. Comments included “they’re very friendly and helpful” and “they explain things clearly so I can understand”.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People said they were satisfied with the care and treatment they received. Comments included, "they've been fantastic", "the doctor is very understanding" and "every doctor I've seen is good".

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People said they felt safe and comfortable using the service. One person said, "I feel safe when I'm here".

People were satisfied with the standards of cleanliness and hygiene at the service. Comments included, "before and after they deal with me I see them wash their hands", "oh yes this surgey is clean". People were protected from the risk of infection because appropriate guidance had been followed.

The provider had an effective system to regularly assess and monitor the quality of service that people received. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.