Brooks Bar Medical Centre NewApproachComprehensive Report … · 2017. 10. 10. · Ourkeyfindingsacrossalltheareasweinspectedwereas follows: • Patientswereatriskofharmbecausenotallstaff

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Inadequate –––

Are services safe? Inadequate –––

Are services effective? Inadequate –––

Are services caring? Requires improvement –––

Are services responsive to people’s needs? Inadequate –––

Are services well-led? Inadequate –––

BrBrooksooks BarBar MedicMedicalal CentrCentreeQuality Report

162-164 Chorlton RoadOld TraffordManchesterM16 7WW

Tel: 0161 226 7777

There is no practice websiteDate of inspection visit: 30th August 2016Date of publication: 24/11/2016

1 Brooks Bar Medical Centre Quality Report 24/11/2016

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 5

The six population groups and what we found 8

What people who use the service say 11

Areas for improvement 11

Detailed findings from this inspectionOur inspection team 12

Background to Brooks Bar Medical Centre 12

Why we carried out this inspection 12

How we carried out this inspection 12

Detailed findings 14

Action we have told the provider to take 25

Overall summaryLetter from the Chief Inspector of GeneralPractice

We first carried out an announced comprehensiveinspection at Brooks Bar Medical Centre, Old Trafford on10th November 2015 when the practice was ratedinadequate overall and was placed into specialmeasures. At that time we also issued the provider with awarning notice because the practice did not haveadequate systems to keep patients safe.

We carried out a focused inspection of the practice on14th June 2016 to review the actions the provider hadtaken in terms of the Warning Notice. At that inspectionthere was evidence that systems had been introduced inorder to reduce risk but they were not yet embedded. Ifthese systems were embedded into every day practiceand followed consistently then users of the service wouldbe kept safe.

Although governance arrangements had improved, manyof the key medical staff, who were instrumental in makingimprovements, had left, or were leaving the practice andthis left overall responsibility with one main lead GP. This

was in addition to their clinical responsibilities and otherlead areas such as safeguarding, significant events,infection control, policies and procedures, humanresources, staff meetings and communication.

We carried out a further announced comprehensivere-inspection of Brooks Bar on 30th August 2016 in linewith our enforcement policy of services placed intoSpecial Measures. The practice had introduced a numberof protocols and business processes to manage thepractice. However, we found that these were notembedded well enough and were not consistentlyfollowed to sufficiently reduce the risks that had beenpreviously identified.

The practice had been unable to recruit substantive GPsand clinical sessions were predominantly covered bylocum staff. We found that safety, effectiveness, care andresponsiveness had deteriorated since our last inspectionbecause locum staff were not involved in the governanceand administration elements at the practice andcommunication was ineffective. The practice is thereforestill rated as inadequate overall.

Summary of findings


Our key findings across all the areas we inspected were asfollows:

• Patients were at risk of harm because not all stafffulfilled their responsibilities to raise concerns, andto report and discuss incidents and near misses.

• We found that where risks were identified andescalated to the lead GP they were not dealt with in atimely manner in order to reduce or preventreoccurrence.

• Patients care plans were in place but they were notpatient specific to be able to meet individual needsand preferences. There were repeated prescribingerrors, and READ coding inconsistencies. (READcoding is a way of grouping specific conditions sothat they can be easily identified and monitored)

• Data showed that some patient outcomes hadimproved since our last visit. However the practicewere still outliers for some of the QOF (or othernational) clinical targets and there was no evidencethat they were being dealt with.

• The practice had implemented a system of audit andmonitoring and had carried out some checks onpatients to ensure they were receiving the mostappropriate treatment.One audit cycle had beencompleted.

• Feedback from patients was mixed.Some patientswere satisfied with the service they had received.Wespoke to seven patients on the day of theinspection.Some were very dissatisfied with theservice and identified confidentiality issues.

• There was good information for patients in thewaiting room about the different services availableto them within and outside the practice. Informationwas transferrable into different languages.

• The practice had implemented a patientparticipation group and the group met regularly.

• The practice had a number of policies andprocedures to govern activity. These were not yetembedded into every day practice to ensure thatthey were effective. For example, to ensure thatappropriate action was taken when things wentwrong.

The areas where the provider must make improvementsare:

• Ensure that all events of significance are reportedand action is taken to ensure they are not repeated.

• Ensure there is a responsible person, with therequired authority, to make sure that action is takenwhen things go wrong.

• Monitor that all staff receive patient safety alerts andensure they are actioned.

• Ensure that policies and procedures are embeddedand appropriate actions are taken when things gowrong.

• Ensure that all complaints, verbal and written, aredealt with appropriately.

• Ensure that all staff receive training in order toeffectively carry out their role.

• Ensure that medicines management is effective.

• Ensure that care planning, system alerts and READcoding on patient records is consistent to identifypatients at the end of their life, those receivingpalliative care, those who are carers and patients inneed of extra support.

• Protect patients’ privacy at all times, specifically inthe reception area.

In addition the provider should:

• Review the needs of the practice population andmake changes where appropriate.

• Continue to review, update and embed proceduresand guidance into day-to-day practice.

• Continue to develop a quality improvement systemto include regular full cycle audits and reviews.

• Introduce a system to identify carers and offer themsupport

This service was placed in special measures in February2016. Insufficient improvements have been made suchthat there remains a rating of inadequate for Safe,Effective, Responsive and Well Led. Therefore we aretaking action in line with our enforcement procedures tobegin the process of preventing the provider fromoperating the service. This will lead to cancelling their

Summary of findings


registration or to varying the terms of their registrationwithin six months if they do not improve. The service willbe kept under review and if needed could be escalated tourgent enforcement action. Where necessary, anotherinspection will be conducted within six months, and if

there is not enough improvement we will move to closethe service by adopting our proposal to vary theprovider’s registration to remove this location or cancelthe provider’s registration

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as inadequate for providing safe services andimprovements must be made.

• Patients were at risk of harm because not all staff fulfilled theirresponsibilities to raise concerns, and to report and discussincidents and near misses. Opportunities to prevent orminimise harm were missed due to ineffective riskidentification and poor management.

• We found that where risks were identified and escalated to thelead GP, they were not dealt with in a timely manner in order toreduce or prevent reoccurrence.There were a number of issuesidentified, including prescribing medication errors.

• Although the practice carried out investigations when there wasunintended or unexpected safety incidents, lessons learnedwere not communicated effectively to staff.

• There were continual issues relating to medicinesmanagement. The practice was high prescribers for hypnoticmedicines and there was no system in place to ensure theseprescriptions were safely reviewed.

• Patients did not receive reasonable support or a verbal andwritten apology. We were aware of three complaints received inthe preceding three weeks that had not yet been dealt with.

• There was not enough consistent medical staff to ensureadequate continuity of patient care and adequate clinicalsupport for the nursing staff.

Inadequate –––

Are services effective?The practice is rated as inadequate for providing effective servicesand improvements must be made.

• Data between July 2014 and June 2015 showed that care andtreatment was not delivered in line with recognisedprofessional standards and guidelines. There were very largevariations in the following items and no evidence of plans toaddress them :▪ The number of Ibuprofen and Naproxen Items prescribed as

a percentage of all Non-Steroidal Anti-Inflammatory drugs;▪ The number of hypnotic medicines prescribed;▪ The percentage of antibiotic items prescribed that are

Cephalosporins or Quinolones▪ The ratio of reported versus expected prevalence for

Coronary Heart Disease (CHD)


Summary of findings


• Patient outcomes were hard to identify as little or no referencewas made to audits or quality improvement.The practicepointed out that they had a higher than average population ofpatients between the ages of 16 and 64 but there was nospecific targeted approach to the needs of this group.

• There was minimal engagement with other providers of healthand social care.

• Staff had been appraised but there was limited recognition ofthe benefit of additional training that may be required.

• Basic care and treatment requirements were not met. Thepractice held care plans for most conditions but these wereonly used by the nurses and health care assistant with noclinical input from a GP. There were no current care plans forpatients receiving mental health, end of life or palliative care.

• Clinical coding was inconsistent making it difficult to identifyand monitor specific groups of patients such as carers,vulnerable patients, and patients on palliative care.

Are services caring?The practice is rated as requires improvement for providing caringservices and there are areas where improvements must be made.

• Patients’ privacy was compromised in the reception areabecause conversations could be overheard.

• There was good information for patients about the servicesavailable to patients in different languages if required.

• Not all staff actively identified carers or knew how to recordthem on the clinical system.

• A number of patients we spoke to said they were not treatedwith compassion, dignity and respect. Not all patients said theyfelt cared for, supported and listened to.

• Data from the national GP patient survey showed patients ratedthe practice lower than others for some aspects of care. Forexample, 76% of respondents said the last GP they saw orspoke to was good at listening to them compared to the CCGaverage of 90% and the National average of 89%.

Requires improvement –––

Are services responsive to people’s needs?The practice is rated as requires improvement for providingresponsive services and improvements must be made :

• There were a limited number of substantive GPs to ensure thatevery clinical session was covered and the practice were unable


Summary of findings


to recruit GPs. Locum staff were used consistently but there wasno guarantee that those locum staff would always be availablewhen required as they were requested on a week by weekbasis.

• Feedback from patients reported that access to a named GPand continuity of care was not always available quickly,although urgent appointments were usually available the sameday.

• Patients could get information about how to complain in aformat they could understand. However, there was no evidencethat learning from complaints had been shared with staff.

• There was no designated person responsible for handlingcomplaints and staff did not fully progress concerns andcomplaints from patients. When concerns were progressed theywere not always dealt with appropriately.

• The practice had a patient participation group but it was notbeing used to implement changes within the practice.

Are services well-led?The practice is rated as inadequate for being well-led andimprovements must be made:

• One GP was responsible for providing the entire leadership ofthe practice and all its associated business needs in addition totheir clinical duties and lead roles such as safeguarding,medicines management, significant events and governanceprotocols.

• There was limited clinical support available for the nursing staffand health care assistant (HCA).

• The future of the practice was wholly dependent on whether ornot the practice could recruit additional GPs. There were nosuccession plans in place.

• Meetings to discuss significant events were not frequentenough to ensure appropriate and timely action was taken toreduce any associated risks. The practice held regulargovernance meetings which were mostly attended byadministration staff and the practice manager.

• The practice had a vision and a strategy but not all staff wereaware of this and their responsibilities in relation to it. Therewas a documented leadership structure and most staff feltsupported by management. Although they felt able to escalateissues, at times they felt that nothing could or would be done toeffect change.

• The practice had a number of policies and procedures togovern activity, but some of these were overdue a review andnot reflected in day to day practice.


Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe provider was rated as inadequate for safe, effective, responsiveand well led and requires improvement for caring. The issuesidentified as inadequate and requiring improvement overallaffected all patients including this population group. We also found:

• Care and treatment of older people did not always reflectcurrent evidence-based practice, and some older people didnot have care plans where necessary.

• Over 75 health checks had recently been implemented andwere being carried out by the Health Care Assistant.


People with long term conditionsThe provider was rated as inadequate for safe, effective, responsiveand well led and requires improvement for caring. The issuesidentified as inadequate and requiring improvement overall affectedall patients including this population group. We also found:

• Nursing staff held lead roles in chronic disease managementand patients at risk of hospital admission were identified as apriority. There were appropriate systems in place for the call,recall and review of patients with long term conditions.

• The percentage of patients with COPD who had a reviewundertaken, including an assessment of breathlessness in thepreceding 12 months was 91% which was higher than the localand national averages of 89%.

• Indicators for all diabetes interventions were lower thanaverage (full detail in the main body of the report) with highexception reporting. Exception reporting is where a practicedoes not include a patient in the overall data submission forspecific reasons.

• Longer appointments and home visits were available whenneeded but there was evidence that home visits were notregular occurrences.


Families, children and young peopleThe provider was rated as inadequate for safe, effective, responsiveand well led and requires improvement for caring. The issuesidentified as inadequate and requiring improvement overall affectedall patients including this population group. We also found:


Summary of findings


• There were systems in place to identify and follow up childrenliving in disadvantaged circumstances and who were at risk, forexample, children and young people who had a high number ofA&E attendances. Immunisation rates were lower than averagefor standard childhood immunisations.

• Staff told us that children and young people were treated in anage-appropriate way and were recognised as individuals, andwe saw evidence to confirm this.

• Although data showed that cervical screening rates were lowerthan average, they had improved.

• Appointments were available outside of school hours and thepremises were suitable for children and babies.

Working age people (including those recently retired andstudents)The provider was rated as inadequate for safe, effective, responsiveand well led and requires improvement for caring. The issuesidentified as inadequate and requiring improvement overall affectedall patients including this population group. We also found:

• Appointments were available from 7.30 am on two mornings aweek and until 7.30pm on three evenings a week.

• There were daily “sit and wait” appointments but these werenot suitable for patients who were working because of waitingtimes of up to an hour or more.

• Prescriptions could be requested by email.• There was no practice website and it was not easy to book

appointments on-line


People whose circumstances may make them vulnerableThe provider was rated as inadequate for safe, effective and well ledand requires improvement for caring and responsive. The issuesidentified as inadequate and requiring improvement overall affectedall patients including this population group. We also found:

• The practice held a register of patients living in vulnerablecircumstances such as children on the “at risk” register.

• The practice offered longer appointments for patients if theyneeded one.

• The practice informed vulnerable patients about how to accessvarious support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adultsand children. Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguarding concernsand how to contact relevant agencies in normal working hoursand out of hours. There were no recent safeguarding incidents.


Summary of findings


People experiencing poor mental health (including peoplewith dementia)The provider was rated as inadequate for safe, effective and well ledand requires improvement for caring and responsive. The issuesidentified as inadequate and requiring improvement overall affectedall patients including this population group. We also found:

• The percentage of patients with schizophrenia, bipolar affectivedisorder and other psychoses who had a comprehensive,agreed care plan documented in the record, in the preceding 12months was 48% which was lower than the local and nationalaverages of 85% and 88% respectively.

• Data showed that 87% of patients with dementia had receiveda face to face review in the previous twelve months but therewas no evidence that the practice carried out advanced careplanning for patients with dementia.


Summary of findings


What people who use the service sayThe national GP patient survey results were published inJuly 2016. The results showed the practice performanceas varied, with some responses much lower than the localand national averages. 363 survey forms were distributedand 90 were returned. This was a 24% completion rateand represented 1.55% of the practice’s patient list.

• 82% of patients found it easy to get through to thispractice by phone compared to the Trafford CCGaverage of 79% and the national average of 73%.

• 62% of patients were able to get an appointment tosee or speak to someone the last time they triedcompared to the Trafford CCG average of 63% and thenational average of 59%.

• 73% of patients described the overall experience ofthis GP practice as good compared to the Trafford CCGaverage of 86% and the national average of 85%.

• 66% of patients said they would recommend this GPpractice to someone who has just moved to the localarea compared to the Trafford CCG average of 81% andthe national average of 88%.

As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection.We received 22 comment cards with mixed responsesabout the standard of care received. Some patients werevery pleased with their care and treatment; some werehappy with the GPs but had concerns about the receptionarea and the staff at reception. Some commentshighlighted concerns about the environment and otherswere very positive about the entire practice.

We spoke with seven patients during the inspection.There were mixed responses. Some patients said theywere satisfied with the care they received and thoughtstaff were approachable, committed and caring. Otherswere dissatisfied with the services or with the way theyhad been treated and responded to when they hadcomplained or provided feedback for consideration.

Areas for improvementAction the service MUST take to improve

• Ensure that all events of significance are reportedand action is taken to ensure they are not repeated.

• Ensure there is a responsible person, with therequired authority, to make sure that action is takenwhen things go wrong.

• Monitor that all staff receive patient safety alerts andensure they are actioned.

• Ensure that policies and procedures are embeddedand appropriate actions are taken when things gowrong.

• Ensure that all complaints, verbal and written, aredealt with appropriately.

• Ensure that all staff receive training in order toeffectively carry out their role.

• Ensure that medicines management is effective.

• Ensure that care planning, system alerts and READcoding on patient records is consistent to identifypatients at the end of their life, those receivingpalliative care, those who are carers and patients inneed of extra support.

• Protect patients’ privacy at all times, specifically inthe reception area.

Action the service SHOULD take to improve

• Review the needs of the practice population andmake changes where appropriate.

• Continue to review, update and embed proceduresand guidance into day-to-day practice.

• Continue to develop a quality improvement systemto include regular full cycle audits and reviews.

• Introduce a system to identify carers and offer themsupport

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included a GP specialist adviser and a practicenurse specialist adviser.

Background to Brooks BarMedical CentreBrooks Bar Medical Practice is a purpose built buildingbased in Chorlton Road, Old Trafford and offers servicesunder a General Medical Services contract to 5,800 patientsin the Trafford and surrounding areas. The practice lies onthe boundary of four areas and the information systemsavailable to the practice do not link with all the secondarycare services where patients can be referred.

The level of deprivation within the practice populationgroup is two (on a scale of one to ten with 10 being lowest).The practice also has a higher population of patients underthe age of 18 compared to the rest of the CCG as well ashigh minority ethnicity such as non-English speakingpatients.

There were two partners at the practice. One of thepartners is responsible for the entire leadership of thepractice and all its associated business needs in addition totheir clinical duties.

The practice are contracted to supply 19 clinical sessionsper week and four administration sessions. One of thepartners and a locum GP regularly undertake eight clinicalsessions. The other clinical sessions are covered by thelead GP and other locum GPs when they can be secured.There are male and female GPs.

Nursing staff consist of two female practice nurses workingpart time, a male health care assistant (assistantpractitioner in training), 10 administration staff and apractice manager.

The surgery opening times are listed as 8am to 7.30pm onMondays, Tuesdays, Thursdays and Fridays, closingbetween 1pm and 2pm for lunch. On Wednesdays thesurgery opens at 8.30am until 12.30pm and does notre-open that day. On Saturdays and Sundays the practice isclosed. It is also closed between 12.30pm and 3pm eachThursday for protected learning time.

When the practice is closed the patients are directed to theOut of Hours Services. The practice tries not to turn anypatients away and sometimes appointments are bookedwhen the reception or surgery is closed. There is anemergency “sit and wait” facility each day and extendedmorning hours are offered on a Tuesday and Thursdaymorning with appointments from 7.30am.

We initially carried out an announced comprehensiveinspection at Brooks Bar Medical Centre, Old Trafford on10th November 2015 when the practice was ratedinadequate and was placed into special measures. We tookenforcement action and issued requirement notices inrelation to Regulations 12 (Safe Care and Treatment), 13(Safeguarding), 18 (Staffing) and 19 (Fit and proper personsemployed). At that time we also issued the practice with awarning notice against Regulation 17 (Good Governance)because there was a lack of systems in place to keep thepractice safe. We carried out a focused inspection of thepractice on 14th June 2016 to check that they had met theterms of the Warning Notice. At that inspection we weresatisfied that adequate systems had been introduced toreduce risks. We were satisfied that if these systems wereembedded into every day practice and followedconsistently then risks would be well managed.

BrBrooksooks BarBar MedicMedicalal CentrCentreeDetailed findings


Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. The inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

How we carried out thisinspectionBefore visiting, we reviewed a range of information we heldabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 30thAugust 2016. During our visit we:

• Spoke with a range of staff including the two GPpartners, the nurses and health care assistant (HCA), themedicines manager and the practice manager, some ofthe reception/administration staff and to patients whoused the service.

• Observed patients in the waiting area and how theywere being treated by staff

• Reviewed an anonymised sample of parts of thepersonal care or treatment records of patients.

• Reviewed comment cards where patients and membersof the public shared their views and experiences of theservice.’

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

We also looked at how well services were provided forspecific groups of people and what good care lookedlike for them. The population groups are:

• Older people

• People with long-term conditions

• Families, children and young people

• Working age people (including those recently retiredand students)

• People whose circumstances may make themvulnerable

• People experiencing poor mental health (includingpeople with dementia).

Please note that when referring to informationthroughout this report, for example any reference to theQuality and Outcomes Framework data, this relates tothe most recent information available to the CQC at thattime.

Detailed findings


Our findingsAt our inspection on 10th November 2015 the practice wasrated Inadequate for Safe. We found that when safetyincidents occurred, reviews and investigations were notthorough enough. Lessons were not communicated widelyenough to support improvement. There were no clearlydefined and embedded systems and processes in place tokeep people safe and safeguarded from abuse. When riskswere assessed the systems and processes in place toaddress those risks were not implemented well enough toensure patients were kept safe for example in relation totraining, health and safety, recruitment checks andDisclosure and Barring Service (DBS) checks. At ourinspection on 30th August 2016 we found the practiceremained unsafe.

At this inspection we found :

Safe track record and learning

The system for reporting and recording significant eventswas still not effective.

• The practice had implemented a system and carried outanalysis of significant events. However we saw that theresponsible person for taking action in many of thereported cases was the practice manager with limitedclinical guidance or support to ensure that action wastaken.

• Staff told us they would inform the practice manager ofany incidents and there was a recording form availableon the practice’s computer system but the evidence tosupport this was inconsistent.We were told aboutincidents which had not been reported or recorded.

• The time between reporting an event and meeting todiscuss and take action could be up to three monthsand locums GPs did not attend these meetings.

• Patients did not always receive reasonable support withinformation and written apology when things wentwrong.Three patients told us that when theycomplained nothing was done.

We reviewed safety records, incident reports, patient safetyalerts and minutes of meetings where these were

discussed. We were not satisfied that lessons were sharedand action was taken to improve safety in the practice.There were repeated incidents of the same issues,particularly in relation to prescription errors.

Overview of safety systems and processes

The practice had introduced systems, processes andpractices to keep patients safe and safeguarded fromabuse but these were not all embedded well enough to beeffective.

• Arrangements were in place to safeguard children andvulnerable adults from abuse.

These arrangements reflected relevant legislation andlocal requirements. The safeguarding policy was dated2015 and was available to all staff on the computersystem.

The policy outlined who to contact for further guidance ifstaff had concerns about a patient’s welfare. There was alead member of staff for safeguarding who said theyattended safeguarding meetings and provided reportswhere necessary for other agencies.

Most of the staff we spoke to demonstrated theyunderstood their responsibilities and all had receivedtraining on safeguarding children and vulnerable adultsrelevant to their role. GPs were trained to child protectionor child safeguarding level 3 and nursing staff were alsotrained to the appropriate level.

• A notice in the waiting room advised patients thatchaperones were available if required. All staff whoacted as chaperones had received guidance and had aDisclosure and Barring Service (DBS) check. (DBS checksidentify whether a person has a criminal record or is onan official list of people barred from working in roleswhere they may have contact with children or adultswho may be vulnerable).

• The practice maintained appropriate standards ofcleanliness and hygiene. We observed the premises tobe clean and tidy. The practice nurse was the infectioncontrol clinical lead and liaised with the local infectionprevention teams to keep up to date with best practice.There was an infection control protocol in place andstaff had received up to date training. There was arecent infection control audit and the results had beenfed back to the team.

Are services safe?



• The arrangements for managing medicines in thepractice were not safe. There were continuing issuesrelating to missing prescriptions and patients receivingrepeat prescriptions that were incorrect. There were noregular medicine audits to ensure that prescribing wasin line with best practice guidelines for safeprescribing.The practice was a high prescriber ofHypnotic medicines which can be addictive; there wasno process in place to review, monitor and reduce theamount prescribed.

• Emergency medicines and vaccines, ordering, storing,security and disposal of medicines were managedeffectively by the nursing staff. Blank prescription formsand pads were securely stored and there were systemsin place to monitor their use. Patient Group Directionshad been adopted by the practice to allow nurses toadminister medicines in line with legislation. HealthCare Assistants were trained to administer vaccines andmedicines against a patient specific prescription ordirection from a prescriber.

• We reviewed personnel files and found appropriaterecruitment checks had been undertaken prior toemployment. For example, proof of identification,references, qualifications, registration with theappropriate professional body and the appropriatechecks through the Disclosure and Barring Service.

Monitoring risks to patients

Risks to patients were still not assessed and well enoughmanaged.

• Although there were procedures in place for monitoringand managing risks to patient safety they were notembedded sufficiently to be effective.

• Arrangements were in place for planning andmonitoring the number of staff and mix of staff neededto meet patients’ needs. There was a rota system inplace for all the different staffing groups but it was notalways possible to ensure enough medical staff to coverthe contractual services required to meet patientdemand. The practice had been unable to recruit fulltime medical staff and most of the sessions werecovered by locums. Where locums could not be secured

the lead GP filled in. The rota showed no GP cover on anumber of Fridays meaning a delay in support fornursing staff and any nursing decisions having to waituntil Monday the followingweek.

• There was a health and safety policy available and thepractice manager was responsible for health and safetywithin the practice. There was an up to date fire riskassessment and fire drills were carried out. There hadrecently been a successful trial evacuation. All electricalequipment was checked to ensure the equipment wassafe to use and clinical equipment was checked toensure it was working properly. The practice had avariety of other risk assessments in place to monitorsafety of the premises such as control of substanceshazardous to health and infection control and legionella(Legionella is a term for a particular bacterium whichcan contaminate water systems in buildings).

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to respond toemergencies and major incidents.

• There was an instant messaging system on thecomputers in all the consultation and treatment roomswhich alerted staff to any emergency.

• All staff received annual basic life support training andthere were emergency medicines available in thetreatment room.

• The practice had a defibrillator available on thepremises and oxygen with adult and children’s masks. Afirst aid kit and accident book were available inreception.

• Emergency medicines were easily accessible to staff in asecure area of the practice and all staff knew of theirlocation. All the medicines we checked were in date andstored securely.

• The practice had a business continuity plan in place formajor incidents such as power failure or buildingdamage. The plan included emergency contactnumbers for staff.

Are services safe?



Our findingsAt our inspection on 10th November 2015 the practice wasrated Requires Improvement for Effective. Knowledge ofand reference to national guidelines were inconsistent.Care was not always planned and delivered following bestpractice guidance such as National Institute for Health andClinical Excellence (NICE) guidance for referrals. There wasno evidence that clinical audit was being carried out andpatient outcomes remained lower than average. Staff werenot effectively appraised and there was little support foradditional required training. At our inspection on 30thAugust 2016 we found that the practice had deterioratedfor providing effective services. Invalidated QoF datashowed that outcomes had deteriorated, there were noprocesses to ensure that guidance was being followed,staffing levels were not sufficient and staff training was stillrequired.


Effective needs assessment

The practice told us they reviewed relevant and currentevidence based guidance and standards, includingInstitute for Health and Care Excellence (NICE) best practiceguidelines.

• The clinical staff we spoke with could outline therationale for their approaches to treatment. However,they had no process to ensure that these guidelineswere being followed, through risk assessments, auditsand random sample checks of patient records.

• There was a system to disseminate medical alerts but itwas not consistent. There was no evidence that two ofthe most recent alerts had been received, disseminatedand acted upon.

Management, monitoring and improving outcomes forpeople

Information about the outcomes of patients’ care andtreatment was collected and recorded electronically inindividual patient records. The practice could provide noevidence of informal or formal clinical peer review andsupport to discuss issues and potential improvements inrespect of clinical care. This included information abouttheir assessment, diagnosis, treatment and referral to otherservices. The computer systems were not used effectivelyby all the clinicians and there was a heavy reliance on the

medical secretary or other staff members to undertakeclinical coding and to type up notes which were eitherdictated in person or via Dictaphone. As a result of thispatient requests were not always being dealt with in atimely manner.

The practice used the information collected for the Qualityand Outcomes Framework (QOF) and performance againstnational screening programmes to monitor outcomes forpatients. (QOF is a system intended to improve the qualityof general practice and reward good practice). The mostrecent published results (2014/2015) were 90% of the totalnumber of points available and the clinical exception was10%. A practice's achievement payments, are based on thenumber of patients on each disease register, known as'recorded disease prevalence'. In certain cases, practicescan exclude patients which is known as 'exceptionreporting'. The non-validated QoF figures for 2015/2016were 72%. This was in line compared to the Localityaverage of 74% and the CCG average of 80%.

This practice was an outlier for several QOF and othernational clinical targets. Data from 2014/2015 showed:

• The percentage of patients on the diabetes register, inwhom the last IFCC-HbA1c was 64 mmol/mol or less was71% compared to the local figure of 77% and thenational figure of 78%.14% of patients had beenexcepted.

• The percentage of patients with diabetes, on theregister, who had an influenza immunisation was 89%compared to the local figure of 95% and the nationalfigure of 94%.19% of patients had been excepted.

• The percentage of patients with schizophrenia, bipolaraffective disorder and other psychoses who had acomprehensive, agreed care plan documented in therecord was 48% compared to the local figure of 88% andthe national figure of 89%. 5% of patients had beenexcepted, which was lower than average.

The practice explained that medical staffing issues were amajor contributor to the low QoF figures and were trying torecruit medical staff into substantial positions. They had sofar been unsuccessful and were heavily reliant on locumGPs to cover clinical sessions. This reduced the practice’soverall effectiveness.

The practice had an audit register and a number of smallaudits had been undertaken such as a review of patients on

Are services effective?(for example, treatment is effective)



Lithium medicines and a review of patients onDomperidone. When identified, information aboutpatients’ outcomes was used to make changes such as newprotocols to reduce the reoccurrence of significant events.However, we found repeats of the same issues despite thisintervention.

Effective staffing

Most staff had the skills, knowledge and experience todeliver effective care and treatment.

• The practice had an induction programme for all newlyappointed staff. This covered such topics assafeguarding, infection prevention and control, firesafety, health and safety and confidentiality. No newstaff had been recruited in the last six months.

• The practice could demonstrate how they ensuredrole-specific training and updating for relevant staff. Forexample the nursing staff and health care assistant hadthe required knowledge to administer vaccines and takesamples for the cervical screening programme. Theyhad received specific training which included anassessment of competence. Staff who administeredvaccines could demonstrate how they stayed up to datewith changes to the immunisation programmes, forexample by access to on line resources and discussionat practice meetings.

• The learning needs of other staff were identified througha new system of appraisal and all staff had recentlyreceived an appraisal.The GP who had conducted theappraisals for the nursing staff and the practice managerhad now left the practice, and there was no plan inplace to ensure that any issues and/or identifiedtraining needs would be met.

• Administration and nursing staff had access toappropriate training to meet their learning needs and tocover the scope of their work. A new on-line educationsystem had been introduced and two hours of protectedlearning time per week had been introduced.Thetraining included safeguarding, fire safety awareness,basic life support and information governance.

• Other training needs such as conflict resolution, goodcustomer service and medicines management had beenidentified through significant events and complaintsthat had been recorded.Despite this we found thatissues were repeated and we were told of continualcomplaints that had not been recorded.

• There was not enough substantive medical staff to coverthe contractual requirements of the practice and theywere heavily reliant on locum staff. Where locum staffcould not be secured the lead GP would cover thesessions.

Coordinating patient care and information sharing

The full information needed to plan and deliver care andtreatment was not completed in patient records.

• There were care plans in place for most conditions butthese were only being utilised by the nursing staff andhealth care assistant.We were informed care plansrequired by patients over 75 years of age had recentlycommenced with consultations taking place by thehealth care assistant.

• No documented care plans had been developed forpatients with mental health issues. Coding errors hadresulted in a patient receiving a dementia related careplan when they did not have dementia.

• One of the GPs was unable to evidence any end of lifecare plans stating that there were no patients currentlyon the plan. This was inconsistent to information fromreceived from other staff.

• A system was in place for hospital discharge letters andspecimen results to be reviewed by a GP who wouldinitiate the appropriate action in response.

• Risk assessments and patient profiling were notmaintained by clinicians. Although clinical meetingswere in place, they were not regular enough and did notinclude GP locum staff. The practice shared relevantinformation with other services but not always in atimely way, such as when referring patients to otherservices, where there had been delays resulting insignificant events.

• We were told that clinicians from othermulti-disciplinary teams such as health visitors,McMillan Nurses and community matrons could attendmeetings if they wanted to.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in linewith legislation and guidance.

• < >taff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005.




When providing care and treatment for children andyoung people, staff carried out assessments of capacityto consent in line with relevant guidance.

• Where a patient’s mental capacity to consent to care ortreatment was unclear the GP or practice nurseassessed the patient’s capacity and, recorded theoutcome of the assessment.

Supporting patients to live healthier lives

The practice identified patients who may be in need ofextra support but did not always take the required action.For example, when we asked one of the GPs about careplans and treatment of patients in the last 12 months oftheir lives they could not produce any care plans. They saidthey had no patients on the plan at present. Action from asignificant event that happened in January 2016 was toconsider an audit after 6 months to check that all staff wereaware of every patient who was identified as dying athome. This had not been done.

There was a register of patients on palliative care and a“watch list” but there was no evidence that these patientswere being “watched” as there were no alerts on thesystem to identify them and no care plans in place.

There was a register with 74 patients who were at risk ofunplanned admissions. Care plans were in place and werereviewed by the nursing staff but they were not utilised orupdated by the medical staff. Patients with learningdisabilities had had a clinical review within the last twelvemonths. There were 21 patients on the register and theregister was maintained by the nursing team.

The practice’s uptake for the cervical screening programmehad improved but was still well below the local andnational averages at 58% (CCG and national average 74%).The nursing staff were pro-actively following up patients toimprove the uptake. The nurses were also monitoring anyinadequate results and following those up.

The uptake for bowel and breast cancer screening was verylow. Females aged 50-70 screened for breast cancer in thelast 3 years was 55% compared to the local average of 68%and the national average of 72%. Persons screened forbowel cancer in the last three years was 38% compared tothe local and national average of 58%. There was noevidence that the practice were doing anything about this.

Cervical cancer screening

Childhood immunisation rates for the vaccinations givenwere comparable to CCG/national averages. For example,childhood immunisation rates for the vaccinations given tounder two year olds ranged from 91-97% and five year oldsfrom 83-96%. The CCG averages were 95-99% and

92-96% respectively.

Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74. Appropriatefollow-ups for the outcomes of health assessments andchecks were made, where abnormalities or risk factorswere identified.




Our findingsAt our inspection of 10th November 2015 the practice wererated Good for caring. The staff at the practice were verycaring and were providing a responsive service for thepopulation groups which were associated with theirpractice such as patients with mental health problems.Data showed that patients rated the practice higher thanothers for some aspects of care such as care and treatmentoffered by the nurse at the practice. Patients said they weretreated with compassion, dignity and respect and theywere involved in decisions about their care and treatment.Information for patients about the services available waseasy to understand and accessible. We also saw that stafftreated patients with kindness and respect, andmaintained confidentiality. At the inspection on 30thAugust 2016 we found that the practice had deteriorated incaring and required improvement. Patient privacy was notbeing maintained, survey results were worse than they hadbeen before and the practice were not doing enough toidentify and support carers.


Kindness, dignity, respect and compassion

We observed members of staff being courteous and veryhelpful to patients in difficult circumstances. However, wereceived information from some patients we spoke to thatthis was not always the case.

• Although reception were aware that patients could betaken to a private room to discuss matters, this wasrarely done due to time constraints or staffingarrangements.We overheard difficult and/or privateconversations taking place in reception between staffand patients in front of other patients. We were also toldabout difficult and/or private conversations beingoverheard by other patients.

• Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments.

• We noted that consultation and treatment room doorswere closed during consultations; conversations takingplace in these rooms could not be overheard.

We received 22 patient Care Quality Commission commentcards. 16 of those were positive about all aspects of theservice experienced. Six cards had comments wherepatients expressed dissatisfaction about the GPs and/orreception staff.

We spoke with six patients. Three of them were satisfiedwith the overall service. All of them mentioned issues withregards to privacy at reception. Three were dissatisfied withthe care or treatment provided and also with the responsesoffered when they complained. We spoke to a member ofthe patient participation group. They told us that the groupwere engaged with the practice and received informationabout the services and asked for suggestions forimprovement.

Results from the national GP patient survey showedpatients felt they were treated with compassion, dignityand respect. The practice was lower than average for itssatisfaction scores on consultations with GPs and nurses.For example:

• 76% of patients said the GP was good at listening tothem compared to the clinical commissioning group(CCG) average of 90% and the national average of 89%.This was less than the previous year’s results of 87%.

• 79% of patients said the GP gave them enough timecompared to the CCG average of 88% and the nationalaverage of 87%. This was less than the previous year’sresults of 87%.

• 91% of patients said they had confidence and trust inthe last GP they saw compared to the CCG average of96% and the national average of 95%. This figure hadnot changed.

• 78% of patients said the last GP they spoke to was goodat treating them with care and concern compared to theCCG average of 86% and the national average of 85%.This was less than the previous year’s results of 82%.

• 83% of patients said the last nurse they spoke to wasgood at treating them with care and concern comparedto the CCG average of 92% and the national average of91%. This was less than the previous year’s results of90%.

• 87% of patients said they found the receptionists at thepractice helpful compared to the CCG average of 89%and the national average of 87%. This was less than theprevious year’s results of 90%.

Are services caring?



The patient survey results had not been discussed at thepatient participation group to ask for ways in which thepatients might effect improvement.

Care planning and involvement in decisions aboutcare and treatment

Some patients we spoke with told us they felt involved indecision making about the care and treatment theyreceived. They also told us they felt listened to andsupported by staff and had sufficient time duringconsultations to make an informed decision about thechoice of treatment available to them. Three of the patientssaid the GPs seemed disinterested in their views and theyfelt they were not receiving the appropriate treatment.Patient feedback from the comment cards was also mixedand aligned with these views.

Results from the national GP patient survey showedpatients views were mixed when responding to questionsabout their involvement in planning and making decisionsabout their care and treatment. Results were lower thanlocal and national averages. For example:

• 84% of patients said the last GP they saw was good atexplaining tests and treatments compared to the CCGaverage of 86% and the national average of 86%. Thisfigure had not changed.

• 75% of patients said the last GP they saw was good atinvolving them in decisions about their care comparedto the CCG average of 83% and national average of 82%.This was better than the previous results of 74%.

• 76% of patients said the last nurse they saw was good atinvolving them in decisions about their care comparedto the CCG average of 86% and national average of 85%

The practice provided facilities to help patients be involvedin decisions about their care:

• Staff told us that translation services were available forpatients who did not have English as a first language.We saw notices in the reception areas informing

patients this service was available.We were also toldthat relatives were regularly used to assist withtranslation because it was difficult to book translatorswhen appointments were emergency or “sit and wait”.

• Information leaflets were available in easy read formatand could be printed in different languages ifrequired.One of the GPs and the health care assistantspoke some of the preferred languages of the patients.

• We saw that there was an appointment checking-insystem available in ten differentlanguages.Unfortunately the system was not utilisedand patients still came to the reception desk whenarriving for their appointments.This causedunnecessarily long queues at reception and patientconfidentiality issues.

Patient and carer support to cope emotionally withcare and treatment

There was a good selection of patient information leafletsand notices were available in the patient waiting areawhich told patients how to access a number of supportgroups and organisations.

The computer system did not alert the GPs if a patient wasalso a carer and therefore they could not be pro-activelyoffered assistance when they attended for treatment. 20patients had been identified as having a carer and werecoded as vulnerable patients. The GPs spoken with saidthat they did not pro-actively identify carers duringconsultations. The practice manager, nurses and healthcare assistant said that they asked patients if they werecarers. 10 patients had been identified as being carerswhich was 0.17% of the practice population.

Staff told us that if families had suffered bereavement theyreceived support in the way of telephone consultations andinformation about other services available to them. One ofthe patients we spoke to said they had received excellentsupport recently when they experienced bereavement.

Are services caring?



Our findingsOur inspection of 10th November 2015 found the practiceto be inadequate for responsive services. Although thepractice had reviewed the needs of its local population, itdid not have a plan to secure improvements for all of theareas identified. For example there was a large number ofpatients with mental health problems which the practiceresponded to, but this had not been discussed with theClinical Commissioning Group to secure improvements.Patients responded differently when asked about makingappointments. Some patients said they could easily makean appointment with a GP of their choice but when theygot to the surgery there were long waiting times.Information about how to complain was available ifrequired. Learning from complaints was not consistentlyshared and reviewed to ensure it was effective. There wasevidence that the same issues kept arising despite changesto protocol. The practice manager was the personresponsible for handling complaints but staff did not fullyunderstand how to process informal concerns frompatients. At the inspection on 30th August 2016 we foundthat the practice remained inadequate for providingresponsive services.


Responding to and meeting people’s needs

The practice was engaged with the NHS England Area Teamand Clinical Commissioning Group (CCG) to secureimprovements to services where these were identified.Areas identified included staffing issues and a possiblemove to new premises.

To meet the demands of the population the practice toldus they offered :

• The practice offered a “Sit and wait” sessions on a dailybasis.

• Longer appointments for patients that needed them.• Home visits when required.• Emergency appointments for children and those

patients with medical problems that require same dayconsultation.

• Travel vaccinations available on the NHS. Patients werereferred to other clinics for vaccines available privatelysuch as yellow fever.

• There were disabled facilities, a hearing loop andtranslation services available.

• A lift for patients with difficulty to reach the upstairsrooms.

• An email service to request prescriptions.

Access to the service

The surgery opening times were listed as 8am to 7.30pm onMondays, Tuesdays, Thursdays and Fridays, closingbetween 1pm and 2pm for lunch. On Wednesdays thesurgery opened at 8.30am until 12.30pm and did notre-open that day. On Saturdays and Sundays the practicewas closed. When the practice was closed the patientswere directed to the Out of Hours Services. The practicetried not to turn any patients away and sometimesappointments were booked when the reception or surgerywas closed. There was an emergency “sit and wait” facilityeach day and extended morning hours were offered on aTuesday and Thursday morning with appointments from7.30am.

Patients did not routinely use on line services to bookappointments and there was no practice website.

Results from the national GP patient survey showed thatpatient’s satisfaction with how they could access care andtreatment was above local and national averages.

• 83% of patients were satisfied with the practice’sopening hours compared to the local average of 77%and national average of 78%.

• 82% of patients said they could get through easily to thepractice by phone compared to the local average of 79%and national average of 73%.

Responses from the seven patients we spoke with on theday were mixed with two saying it was easy to get anappointment when they wanted it and the others finding itvery difficult to get through to the practice on thetelephone.

The system to assess whether a patient required a homevisit was not clear. There were telephone consultationsavailable and we were told that patients always received acall back if there was any doubt. There were home visitappointment slots available each day. We were told ofexamples where staff had correctly identified that a patientshould access accident and emergency rather than comingin to the surgery. We also had evidence that the number ofpatients attending A&E between April 2015 and March 2016was 430. This was higher than the local average of 419 andCCG average of 374.

Are services responsive to people’s needs?(for example, to feedback?)



Data we held also showed that more patients from thispractice (95) had a face to face or telephone contact withthe out of hours services. This was higher when comparedwith the CCG average of 76.

The practice was commissioned to provide 21 clinical and 4administration sessions per week. There was not enoughmedical staff to ensure that these sessions were continuallycovered on a week by week basis. Administration staff toldus that they found it difficult to manage the appointmentsystem because they did not always know far enough inadvance whether a doctor would definitely be available tocover the sessions. This meant it was not always possible tobook appointments in advance. One of the salaried GPscovered three sessions, a long-term locum covered twosessions and the lead GP covered three to nine sessions(dependant on whether locums were available). Theremaining ten sessions were covered either by the lead GPor by locum GPs.

Listening and learning from concerns and complaints

The practice did not have an effective system in place forhandling complaints and concerns.

• The complaints policy and procedure was in line withrecognised guidance and contractual obligations forGPs in England but it was not being followed.

• The practice manager appeared to be the responsibleperson who handled all complaints in the practice. Ifthey were unable to deal with them they delegatedaction to the lead GP. There was evidence that therequired action was not always taken.

• There was information to help patients understand thecomplaints system but the practice did not encourageand record verbal complaints in a way that they couldbe discussed and analysed to ensure that they were notrepeated.

We looked at a summary of eight complaints that had beenrecorded between January and June 2016. We saw that:

• They were discussed within the practice and action wasidentified and we saw evidence that some action, suchas staff training, was undertaken.

• We saw repeated issues had been raised to the practicewith no plan to resolve these issues.

• There was no evidence that all patients that complainedreceived a satisfactory response.We spoke to patientswho had made a complaint and were not happy withthe response.

• The lead GP told us that there was only one “on-going”complaint. However we were made aware of threecomplaints that had recently been received. Thesecomplaints were about repeated issues and had not yetbeen discussed although a meeting had been plannedat the request of the practice manager.

Are services responsive to people’s needs?(for example, to feedback?)



Our findingsOur inspection of 10th November found the practice to beinadequate for Well Led. The leadership structure wasfragmented and the GPs worked in isolation. However,there was new and impressive leadership coming from theone of the newly appointed partners and improvementswere being made. There was a vision to provide responsive,effective, safe and well led care, and the values of staff werein line with that vision, but lack of effective leadershipmade that impossible to sustain. Staff felt supported bymanagement and listened to, but unable to effect change.The practice had a number of policies and procedures togovern activity, most of which were overdue a review.Feedback from patients had recently been initiated by wayof a patient participation group (PPG) and work to developthat relationship was in its initial stages. The learning needsof staff were identified through a system of appraisals,meetings and reviews of practice development needs.However, staff did not have access to appropriate trainingto meet those needs. At the inspection on 30th August 2016we found that the practice remained inadequate for beingwell led.


Vision and strategy

The lead GP had a vision to deliver high quality care andpromote good outcomes for patients and shared thisexpectation with the other staff. However there was nomedical support to sustain this vision. The administrationand nursing staff shared the vision but felt unable to effectchange.

Governance arrangements

The overarching governance framework in the practice wasweak and did not support the delivery of safe and effectiveclinical care. All the partners at the practice had eitherretired or were due to retire at the end of the year and therewas no immediate solution for their replacement otherthan locum GPs. The lead GP remained with overallresponsibility for all clinical and business decisions. A newgovernance structure and new policies and procedures hadbeen introduced by one of the new partners the previousyear. This partner had now left and since then the structure

had not been maintained throughout the practice despitethe efforts of the practice manager to continue what hadbeen started. The practice had been unable to evidencethat the new system was being used and was effective.

• There was a staffing structure in place and staff wereaware of their own roles and responsibilities.

• The lead GP was responsible for all lead areas within thepractice. This included safeguarding, clinical support,appraisal, training, significant events, risk management,audit and overall decision making. This was in additionto their clinical duties, and cover for any clinical sessionsthat could not be met by locum staff.

• Whilst a system of clinical audit was in place there was alack of internal checks and audits to monitor the qualityof the services and a lack of clinical and medical staff tocarry out clinical audits.Where issues were identifiedthere was a lack of action taken to make improvements.

• Arrangements for monitoring risks were not effective.

Leadership and culture

The lead GP did not share the concerns of CQC about therisks in relation to the practice and maintained that riskswere well managed and controlled. Staff told us thepartners were approachable and always took the time tolisten to all members of staff. However, they felt that actionwas not always taken to make improvements. Althoughthere were two partners at the practice we were told thatone was salaried, and only the lead GP had the authority tomake decisions.

The practice did not always support people whocomplained, and did not deal with complaints in an openand transparent way. Not all patients who had complainedreceived reasonable support, information about what wentwrong and why, and a verbal and/or written apology.Complaints were not encouraged so that they could beanalysed in an open way to reduce repeated issues.

There was a clinical structure in place and staff said theyfelt supported. Lines of communication had improved andadministration staff specifically felt more empoweredhaving received protected learning time and better trainingto help them in their role.

• Staff told us the practice had started to hold regularteam meetings.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



• Staff told us there was an open culture within thepractice and they had the opportunity to raise anyissues and felt confident in doing so.

• Staff said they felt respected, valued and supported bythe partners in the practice.

Seeking and acting on feedback from patients, thepublic and staff

The practice said they encouraged and valued feedbackfrom patients, the public and staff.

• They had gathered feedback from patients through thepatient participation group (PPG) and through surveysand complaints received. The PPG met regularly, andreceived information about the practice but we did not

see anything to evidence any improvements had beenbrought about because of feedback from this group.The group were not entirely representative of thepatient population because there was no website todisplay information and present minutes from meetings.

• We spoke to members of the PPG who told us that theyfelt unable to help the practice and unable to effectchange.

• The practice had gathered feedback from staff through arecent survey and had identified that staff satisfactionhad improved. Staff told us they would not hesitate togive feedback and discuss any concerns or issues withcolleagues and management, although they said actionwas not always taken to change things.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 10 HSCA (RA) Regulations 2014 Dignity andrespect

How the regulation was not being met:

The practice did not ensure that patient privacy wasmaintained at all times.

Regulation 10(1)




Surgical procedures


Regulation 16 HSCA (RA) Regulations 2014 Receiving andacting on complaints

How the Regulation was not being met:

Complaints were not always responded to andappropriate action was not always taken to come to asatisfactory resolution. Patients did not always receivesupport , appropriate information and a verbal and/orwritten apology.

Regulation 16(1) and (2)




Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

How the Regulation was not being met:

Although the practice had introduced adequate policiesand procedures, and systems to manage risk they werenot sufficiently embedded and consistently followed toensure that patients were kept safe.

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


The practice did not have effective systems or processesin place for clinical review and care planning or patientprofiling. This was evident in relation to patientsreceiving palliative care and carers.

Clinical IT systems were not used effectively to identifypatients with in need of extra support.

Systems to manage medicines were not maintained andeffective to keep patients safe. We identified continuingissues relating to prescription errors, with no suitablearrangements in place for the safe monitoring ofHypnotic medicines, Non-Steroidal anti-inflammatorydrugs and antibiotics.

The system to disseminate patient safety alerts was noteffective.

Significant events were not dealt with appropriately andaction was not taken in a timely manner to preventrepeated issues. There was no responsible person withappropriate authority who ensured that action wastaken when things went wrong.





Surgical procedures


Regulation 18 HSCA (RA) Regulations 2014 Staffing

How the regulation was not being met:

There was not enough substantive medical staff to coverall the clinical sessions and ensure continuity and safecare for patients.

The practice manager did not receive appropriatesupport, training, professional development andsupervision to enable them to carry out the duties theywere employed to perform.


Regulation


Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.


Enforcement actions


Documents

Brooks Bar Medical Centre NewApproachComprehensive Report … · 2017. 10. 10. · Ourkeyfindingsacrossalltheareasweinspectedwereas follows: • Patientswereatriskofharmbecausenotallstaff