Archived: Merseybank Surgery

Updated 4 May 2017

Merseybank Surgery is situated in a deprived area of Chorlton within South Manchester Clinical Commissioning Group area . It is located in a row of shops and has disabled access and toilet facilities. Dr Hotchkies is a single-handed, male practitioner who has provided GP services at this location for over twenty five years under a General Medical Services contract.

The practice population is around 2,600 patients, currently increasing, and has a higher than average proportion of patients between the ages 15 and 49. The highest group of patients are aged between 25 and 29, higher than the local and national average. The number of patients over the age of 65 is less than the local and national average at fewer than 2%.

Staff at the practice consist of the lead GP, a part time practice manager and three part time administration staff. The part time (one day per week) practice nurse has left the practice and the gap will be filled by agency nurses in the interim. The practice does not offer surgical procedures, maternity or midwifery services or minor injury treatments. These can be accessed through the local community services. Child surveillance clinics are provided by a buddy practice nearby. There is no female GP.

The surgery is open from 8.30am until 6pm Monday to Friday (except Wednesdays). On Wednesday the practice closes at 1pm. Patients are directed to out of hours services when the practice is closed after 6pm and at the weekend.

Patients have access to an open surgery from 9.15am until 11.30am Monday to Friday and appointments are pre-bookable in the afternoons (except Wednesdays). The practice has a website and patients can register and request access to their medical records, make appointments and request prescriptions.

We initially carried out an announced comprehensive inspection at Dr Iain Hotchkies Merseybank Surgery on the 14 July 2015 when the practice was rated inadequate overall and was placed into special measures. Services placed into special measures are re-inspected again within six months. We also issued a warning notice to ensure the practice immediately carried out actions required to meet Regulation 12, Safe care and treatment.

On 4 April 2016 we carried out an announced full comprehensive re-inspection when we found the practice had made improvements but remained inadequate for safety. We found that other improvements were still required and overall the practice was rated as requires improvement. The practice were placed into special measures for a further six months and given a warning notice for concerns relating to Regulation 17, Good Governance.

Updated 4 May 2017

Letter from the Chief Inspector of General Practice

We initially carried out an announced comprehensive inspection at Dr Iain Hotchkies Merseybank Surgery on the 14 July 2015 when the practice was rated inadequate and was placed into special measures. Services placed in special measures are re-inspected again within six months.

On 4 April 2016 we carried out an announced re-inspection of Merseybank Surgery when the practice had made improvements but remained inadequate for safety and continued in special measures for a further six months. Although improvements had been made, further improvement was still necessary and overall the practice was rated as requires improvement.

This most recent inspection was an announced comprehensive re-inspection undertaken on 31 January 2017 following the continued period of special measures. Overall the practice had received a period of eighteen months to improve since its initial rating of Inadequate. At this inspection we found that the practice had made only minor improvements in some areas, but had not progressed at all regarding other improvements required. Overall the provider has been given significant time to make improvements but the findings of this inspection indicate that they are not able to maintain the improvements required. As the provider has not been able to make more substantial improvements over a prolonged period of time, the practice is rated as inadequate.

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

• Although some minor improvements were evident they did not fully reflect all the areas identified for improvement in the previous inspection reports. Significant shortfalls remained regarding the quality of the service.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons and actions were highlighted but were still not carried out. There was no understanding of the requirement to review incidents to ensure that learning had been achieved and this had been highlighted at the previous inspection.
• When risks to patients were identified they were not always well managed and appropriate action was not always taken.
• The practice had a number of policies and procedures to govern activity, but they were not all followed in accordance with what they contained.
• Health checks, childhood immunisations and cervical screening rates remained lower than average compared with the local CCG and national averages.
• A patient participation group had been implemented but the practice did not find it useful and there was limited benefit to the practice or its patients.
• Improvements had been made to patient outcomes and data showed that the majority of patient outcomes were comparable to the CCG and national average.
• Effectiveness at the practice had progressed and there was evidence that clinical audit was being used to improve patient outcomes.
• All the patients we spoke to or provided written feedback said they were treated with compassion, dignity and respect.
• The practice offered open surgeries each morning and fixed appointments each afternoon except Wednesdays when the practice was closed.
• Patients had been informed that a merger of the practice was imminent but no formal arrangements had yet been agreed.

The areas where the provider must make improvements are:

• Have systems and processes that are established and operated effectively to ensure that good governance is maintained.
• Do all that is reasonably practicable to assess, monitor, manage and mitigate risks to the health and safety of patients.
• Monitor and review that staff have the required training and understanding to enable them to carry out their roles effectively.
• Have a system to obtain patient feedback and monitor verbal comments and complaints
• Ensure care and treatment is provided in a safe way.
• Take appropriate action whenever risks and issues are identified.
• Ensure that care plans are in place for all patients that need them.
• Have a system to ensure competency and understanding of training such as chaperoning and Data Barring and Service (DBS) checks.
• Be able to demonstrate sufficient understanding of the requirements of the Health and Social Care Act 2014 and how to implement and maintain the necessary changes
• Demonstrate that they have the necessary qualifications, competence, skills and experience required to undertake their role, such as mental capacity, Deprivation of Liberty Safeguards (DoLS) and leadership skills.

The areas where the Provider should make improvements are as follows :

• Have a system to identify and support those patients that are carers.
• Consider a continual review of procedures and guidance to ensure they are being followed.
• Consider the needs of the practice population and make changes where appropriate such as increasing the number of staff or maximising the skills of existing staff to meet these needs.

This service was originally placed in special measures in July 2015. The service was kept under review for six months and a re-inspection was conducted in April 2016. The practice was advised that if there was not enough improvement further action could be taken in line with our enforcement procedures.

The practice was re-inspected for a third time in January 2017. Insufficient improvements have been made such that the rating remains as inadequate overall. We are therefore taking action in line with our enforcement procedures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 May 2017

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• There were no specific clinics for patients with chronic diseases. We were told that patients were regularly invited for reviews which were undertaken by the GP. A diabetic nurse attended the practice on a monthly basis.
• The practice nurse had recently left and there was no plan in place for agency nursing staff to have lead roles in chronic disease management which was managed by the GP.
• There was still no formal process to monitor patients at risk of hospital admission which was highlighted at the last CQC inspection.
• Not all patients with long term conditions had care plans that were regularly reviewed.
• Longer appointments and home visits were available when needed.
• For those patients with the most complex needs, the named GP told us that they worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 4 May 2017

Families, children and young people

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• 59% of the registered population was under the age of 40 years and 13% were under the age of 10 years. This was higher than the CCG and national averages (50% and 11% respectively).
• Although improved, cervical screening rates were still lower than the CCG and national averages. The percentage of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding 5 years was 71% compared to the CCG average of 82% and the national average of 82%.
• The expected standard for immunisation rates was 90%. Immunisation rates for this practice were low (72% and 87%) for two out of the four requirements for children under the age of one year. There were no specific immunisation clinics.
• Child health surveillance services were provided by a nearby buddy practice.
• The GP did not demonstrate during discussions that Gillick and Fraser guidelines were followed. These guidelines support sole decision making in children under the age of 16. The GP told us that children mostly attended appointments with a parent.
• There was an informal system in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. There was a risk register in place but this was not systematically looked at or reviewed.

Updated 4 May 2017

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• The practice had a lower than local average older population. 10% of patients were over 65 (national average 16%) and 4% were over 75 (national average 8%).
• Care and treatment for this small number of older people did not always reflect current evidence-based practice, for example some older people did not have care plans where necessary as the GP did not consider them effective.
• Seven patients had been identified and were on the dementia register. They received appropriate investigations and were referred for memory tests.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older people such as dementia, atrial fibrillation (heart disease) and risk of stroke were 100% which was above average.

Updated 4 May 2017

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• The practice did not offer pro-active appointments for health checks and there was low uptake for health screening such as breast and bowel cancer. For example females aged 50-70 screened for breast cancer in the last 36 months was 55% compared to the CCG average of 63% and national average of 73%.
• The practice had introduced on line services and patients could register and request access to their medical records. They could also make appointments and repeat prescription requests.
• There was sufficient health promotional advice and accessible information in the waiting room and a notice board with community news and support agencies.
• Patients were able to drop in to see the GP every weekday morning and could make specific appointments in the afternoon.

Updated 4 May 2017

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• Patients with mental health illnesses were prescribed medicines to keep them stable. The practice remained outliers for the prescription of hypnotic medicines (sleeping pills). The GP told us that they had discussed reduction regimes with patients but they had not implemented any reduction programmes.
• The GP still did not carry out regular physical and mental health review of patients with mental illness but had identified 23 patients and had generated and agreed care plans with 10 of them.
• The practice did not have a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health. Not all staff had received training on how to care for people with mental health needs and the GP had not undertaken recent training on the Mental Health Act 2015 or Deprivation of Liberty Safeguards (DoLS) although this was planned for the future.
• 100% of patients identified and diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months.

Updated 4 May 2017

Due to the continuing issues the provider is rated as inadequate in safe and well led and requires improvement for effective and caring services. The issues identified in those domains overall affected all patients including this population group.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. However, while children were identified as being at risk through the risk register, they were not routinely reviewed or monitored
• The practice was identifying patients with a learning disability and longer appointments were always available if required.
• The practice was now working with other health care professionals in the case management of vulnerable patients although there was limited documentation to support that.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.