Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Victoria Park Medical Centre (previously Doctors Lewis, Hawkes and Dicks) on 30 November 2016 to check if improvements have been made in response to our previous inspection on 3 February 2016 when the practice was placed in special measures following an overall rating of inadequate. Overall the practice is now rated as good.

On 3 February 2016 we found the practice was inadequate for the safe and well led domains and required improvement for the responsive domain. We found the practice was good for effective and caring domains. This led to an overall rating of inadequate. We also rated the services for the specific population groups inadequate to align with these ratings. Following the inspection, which raised significant concerns, we placed the practice into special measures. Being placed into special measures represents a decision by Care Quality Commission (CQC) that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

We issued warning notices in regard to:

• Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance.
• Regulation 18 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Staffing.

On 16 June 2016 we inspected the practice to check compliance had been met in regard to the warning notices. We found the provider had made significant steps to ensure the concerns which had been found previously in relation to the warning notices for Regulations 17 and 18, had or were in the process of, being addressed. The practice remained under special measures until we returned to carry out a comprehensive inspection at the end of the six month period after the initial report was published.

Our key findings across all the areas we inspected on 30 November 2016 were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained, to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The practice had a higher than local average of patients recorded as obese. They had undertaken an audit on patients who had undergone bariatric surgery and developed a register of these patients. A recall system for follow up tests, injections and annual reviews had bene implemented. (Bariatric surgery is a procedure to reduce weight through reduction of the size of the stomach).
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent and routine appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

However there were areas of practice where the provider should make improvements:

• The provider should have a system in place to demonstrate action is taken to address any improvements when highlighted in infection control audits.

This service was placed in special measures in April 2016 in order for the provider to take steps to improve the quality of the services it provided. I am taking this service out of special measures. This recognizes 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 Doctors Lewis, Hawkes and Dicks, known as Victoria Park Medical Centre on 3 February 2016. Following our comprehensive inspection overall the practice was rated as inadequate with an inadequate rating for the safe and well led domains and requires improvement for the responsive domain. We were so concerned following this inspection we placed the practice into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Both the domains of effective and caring were rated as good. We were so concerned with some aspects in the safe and well led domain that we took further steps to ensure that the practice made changes to the governance of the service to reduce or eliminate the risks to patients. The provider was required to make improvements in respect of these specific deficits, as outlined in the warning notices by 13 June 2016.

We issued warning notices in regard to:

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

• Regulation 18 of the Health and Social Care Act (Regulated Activity) Regulations 2014,Staffing.

The warning notice in relation to regulation 17 was that the provider must implement the necessary changes to ensure an effective system or process. This is in order to assess, monitor and improve the quality and safety of the services provided. This included for the provider to have a system to assess monitor and mitigate risks relating to the health, safety and welfare of service users and others who may be at risk arising from the carrying out of the regulated activities.

The warning notice in relation to regulation 18 was that the provider must implement the necessary changes to ensure that they deploy sufficient numbers of suitably qualified, competent, skilled and experienced persons. This is in order to meet the requirements of the population they served. The provider also needed to ensure that persons that are employed are receiving appropriate support and training as required in line with their role and responsibilities.

A copy of the full report detailing our findings from the inspection 3 February 2016 can be found at www.cqc.org.uk.

This inspection undertaken on the 16 June 2016 was to check compliance had been met in regard to the warning notices for regulations 17 and 18 and will not change the current rating of the service. Other areas of non-compliance will be reviewed at a later date when a full rated comprehensive inspection is undertaken and the practice have had time to implement the changes required.

Our key findings across all the areas during this focused inspection were as follows The provider had made steps to ensure the significant concerns that had been found previously in relation to the warning notices for regulations 17 and 18 had or were in the process of being addressed:

• The provider had taken steps in increasing the stability of clinical provision in order to provide treatment and care to patients. The lead GP has maintained a regular group of either salaried GP, locum GPs or a salaried nurse practitioner to provide clinical care to patients, ensuring there was continuity of care.

• The provider had made changes in order that two staff were always covering the reception desk and ensuring that staff were answering the telephone as promptly as possible. We saw positive feedback received by the practice from patients that the changes already implemented had improved the patient experience in regard to accessing the service either by telephone or at reception.

• The provider had put processes in place to support new staff and locum GPs and nurses when they started working at the practice to ensure they were well equipped to provide a safe service.

• The provider had reviewed how they responded and managed any significant events. Significant events had been incorporated into the regular Wednesday meetings and there was evidence that all aspects were discussed and actions to be taken planned for and reviewed for their effectiveness.

• The provider had implemented changes to the arrangements in place at the practice to safeguard children and vulnerable adults from abuse. Ensuring that information and support was available for staff in order to respond to concerns effectively.

• Steps had been made by the provider in regard to a management system to ensure clinical and non-clinical staff were up to date with their routine immunisations and immunisations for staff for specific disease prevention.

• We found the practice was now following legal requirements and national guidance when administering vaccinations and immunisations. The practice had a process to ensure that Patient Group Directions (PGDs) were adopted allowing nurses to administer medicines in line with legislation.

• The practice had implemented changes to the management and administration processes for recruitment of staff. Disclosure and Baring Service (DBS) were being carried out on all staff and a risk assessment process to determine the suitability of staff had been implemented whilst this was being completed.

• The practice had commenced a programme to assess and implement a system. This was order to identify, monitor and to ensure the provider had an oversight of risk assessments and safety checks and to promote patient and staff safety. Progress in this area will be reviewed when we next undertake a comprehensive inspection at the practice.

• The provider had made changes in how patients were informed and supported on how to make a complaint.They had set up a new process for how complaints were managed and we saw evidence that this was effective.

• The provider had implemented changes to the management and governance systems. The provider had engaged a new interim practice manager to take the lead, working with the provider in shaping the changes in the organisation of the service.

• We saw that progress was being made in implementing a structured filing system for non-clinical practice business. This meant that information was more accessible to staff in the absence of the practice manager. Progress in this area will be reviewed when we next undertake a comprehensive inspection at the practice.

In this situation with the issuing of warning notices, we returned to check the progress the provider was making in regard to the key concerns. The practice remains under special measures until we have returned to carry out a comprehensive inspection at the end of this six month period after the initial report was published. If the service has failed to make sufficient improvements the CQC will consider taking steps to 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 comprehensive inspection at Doctors Lewis, Hawkes and Dicks on 3 February 2016. Overall the practice is rated as inadequate.

We found the practice inadequate for providing safe and well-led services. The practice requires improvement for responsive services and good for effective and caring 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. However, reviews and investigations were not thorough enough. Patients did not always receive a verbal and written apology.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

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

• The practice employed a prescription administrator which resulted in good processes and systems for the handling of prescription safety.

• Patients said they did not find it easy to make an appointment with a GP.

• Appointment systems and access via telephone were not working well so patients did not receive timely care when they needed it.

• The practice had a number of policies and procedures to govern activity. However some were overdue a review and did not contain up to date information. This meant there was no surety they met the needs of the service.
• The practice had a newly formed patient participation group.
• Clinical 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.

• The practice had no clear non clinical leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• Improve the access to the practice through the telephone system and the availability of appointments during core practice hours.

• Review the process and procedures for patient complaints and significant events and introduce robust processes for reporting, recording, acting on and monitoring complaints and significant events. Ensure appropriate and accessible signposting for patients around the complaint system.

• Ensure policies and procedures are easily accessible to staff; are updated to reflect current guidelines and legislation and contain, where necessary referral pathways. For example, the safeguarding vulnerable adults reporting processes. Implement a staff checking system for staff understanding, changes and updates to policies.

• Review the recruitment policy /procedures and arrangements to include all necessary employment checks for all staff are completed before employment commences and role and location specific induction packs are available for all staff including locums.

• Ensure appropriate, legal and that relevant governance arrangements are in place for Patient Group Directions (PGDs).

  Ensure there is a holistic and comprehensive understanding of safety systems in place with managerial oversight of and documentation of risk assessments and safety checks. For example, fire drills, staff immunisation records, legionella and a system for checking of and calibration of medical equipment.

• Ensure there are effective structures, processes and systems of accountability in place which reflect a systematic approach to maintaining and improving the quality of patient care and service delivery.

• Ensure adequate support for GP partners in the non-clinical business management of the practice.

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 or vary the terms of their registration with the Care Quality Commission. Being placed into special measures represents a decision by the Care Quality Commission (CQC) that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Special measures will give patients who use the practice the reassurance t the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice