Archived: Welland Medical Practice

We carried out a comprehensive inspection of Welland Medical Practice on 29 November 2018. The practice was rated as inadequate for providing safe, effective, responsive and well led services, and rated as requires improvement for caring services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for regulation 12 (Safe care and treatment) and a requirement notice for Regulation 17 (Good governance).

The practice was previously inspected in April 2016 and rated as good overall and for providing effective, caring, responsive and well led services and rated as requires improvement for providing safe services. We undertook a desk top review of the safe domain in September 2016 and rated the practice as good for providing safe services.

You can read our findings from our last inspections by selecting the ‘all reports’ link for Welland Medical practice on our website at www.cqc.org.uk.

This inspection on 25 June 2019 was an announced comprehensive inspection. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.

At this inspection we found:

• Improvements had been made since our last inspection, however some of these needed to be fully implemented, further improved, embedded and monitored to ensure they were sustainable to ensure patients received safe and effective care.
• There had been significant staff changes within the practice and new staff had been employed including two practice nurses, and advance nurse practitioner and practice manager. A pharmacist was awaiting the completion of their pre-employment checks before commencing work within the practice.
• The GP lead and staff told us there had been an increase in the morale and leadership and they were proud of the improvements made so far but recognised there was still improvements to make.
• The practice had support from the CCG and the Royal College of General Practitioners to ensure effective and detailed action plans to drive and sustain the improvements required.
• The practice operated from premises that no longer met the needs of the local population. The practice was actively working with the Clinical Commissioning Group to ensure that new premises being built nearby were completed; however, there were delays in this project and the practice had not been able to move in April 2019 as planned, a provisional date for September 2019 was in place.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.

At this inspection we have rated the provider as requires improvement for providing safe services because:

• Some improvements had been made, for example to the management of emergency medicines and the practice had undertaken regular checks on health and safety issues. However, we found that some further improvements, implementation and embedding of new systems were still required as:
• Not all safety alerts were acted upon and monitored.
• Further improvements were needed to the recruitment procedures to ensure only fit and proper persons are employed. Not all the specified information was available regarding each person employed.
• Staff induction records did not contain sufficient details to give assurance that staff had been assessed as competent to undertake their role and responsibility.
• On the day of the inspection the practice was not able to evidence that all staff had received appropriate safeguarding training.
• The system used to monitor repeat medicines was consistent and recorded to allow easy monitoring.

We rated the practice as good for providing effective services for all population groups except those whose circumstances made them vulnerable because;

• The practice had made improvements to the management and effectiveness of the care and treatment to patients. Although the practice had improved the number of annual reviews undertaken for this group of patients since our last inspection, only 42% of patients with a learning disability had received a comprehensive annual review. The practice had sent invites to other patients and were encouraging uptake of these appointments.

We rated the practice as requires improvement for providing caring services.

• At our previous inspection published January 2019 we rated the practice as requires improvement for providing caring services because generally, feedback from patients showed that staff did not always treat patients with kindness, respect and compassion. There is insufficient evidence to show the practice has made necessary improvements within the practice to improve patient satisfaction. Therefore, caring is still rated as requires improvement.

We rated the practice as inadequate for providing responsive services because:

• Data from the 2018 GP Patient Survey showed patients satisfaction regarding access to the practice was low. Some comments on NHS choices and on the comment cards we received reported negative experiences. Since our last inspection, the practice had made some changes but had not assessed the impact of this.

We rated the practice as requires improvement for providing well led services because:

• The provider had improved some systems and processes to ensure care and treatment was provided in a safe way to patients. However, some of these improvements needed to be fully implemented, embedded and monitored to ensure improvements were sustained.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Review and improve the system to ensure patients who have a learning disability receive appropriate and timely review.
• Review and improve the system to identify carers to ensure they receive appropriate support.
• Review and monitor patient feedback to ensure patients receive timely access to GPs and nursed.
• Implement further systems to encourage patients to partake in the national cancer screening programme including breast and bowel cancer screening.

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

This service will remain in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Welland Medical Practice on 29 November 2018 as part of our inspection programme. The practice was previously inspected in April 2016 and rated as good overall and for providing effective, caring, responsive and well led services and rated as requires improvement for providing safe services. We undertook a desk top review of the safe domain in September 2016 and rated the practice as good for providing safe services.

Our inspection team was led by a CQC inspector and included a GP specialist advisor.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall.

We concluded that:

• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• The practice operated from premises that no longer met the needs of the local population. The practice was actively working with the Clinical Commissioning Group to ensure that new premises that were being built nearby were completed and they told us they should move into them by end of April 2019.

However, we also found that:

• People were not adequately protected from avoidable harm and abuse.
• There was insufficient assurance that people received effective care and treatment.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

We rated the practice as inadequate for providing safe services because:

• The practice failed to evidence they had recruited staff safely.
• The practice did not provide evidence to demonstrate they had an effective induction system in place for new staff members. The provider had not ensured all staff had been appropriately trained to undertake the clinical tasks delegated to them.
• The practice had not ensured patient specific directions were signed prior to the healthcare assistant administering injections.
• GPs did not regularly attend safeguarding or multidisciplinary meetings that were held to discuss their patients. Minutes of the meetings were circulated to the GPs after the meeting for information.
• The practice was up to date on the summarising of medical records but they did not have a system in place to ensure they monitored the quality of the coding made by non-clinical staff or a system in place to monitor any delays in referrals and mitigate any risks.
• The practice had not implemented effective systems to ensure appropriate and safe handling of medicines or emergency medicines.
• The practice systems and processes to ensure all actions identified from significant events were actioned and monitored needed to be improved. There was no clear evidence to demonstrate identified learning was shared with the whole practice team.
• The practice had not undertaken regular water sample tests and could not provide evidence to demonstrate they regularly undertook water temperature tests to monitor and manage the risk of Legionella.

We rated the practice as inadequate for providing effective services because:

• The monitoring of some of the outcomes of care and treatment needed to be improved. For example, the practice performance in relation to prescribing hypnotics was above the CCG and national average. The practice had not undertaken any reviews or monitoring such as clinical audit to ensure they were prescribing effectively.
• The provider did not demonstrate that all staff had the skills, knowledge and experience to carry out their roles. The management team did not have clear clinical oversight of the training needs and competency of staff.
• Due to the shortage of trained staff, the practice had offered limited access to appropriate health assessments and checks including NHS checks for patients aged 40-74. For example, the practice had undertaken 11 NHS reviews, and no reviews for carers or reviews for patients with learning disabilities.
• The practice held regular monthly meetings with the health visitor and school nurse to discuss concerns however the GPs did not regularly attend these meetings but kept up to date via the minutes that were recorded and shared with them.
• The practice had not reviewed the uptake of the national screening programme in relation to breast and bowel cancer. Both indicators were below the CCG and national averages, the practice did not have systems and processes in place to encourage uptake.

We rated the practice as requires improvement for providing caring services because:

• Generally, feedback from patients showed that staff did not always treat patients with kindness, respect and compassion.

We rated the practice as requires improvement for providing responsive services because:

• Data from the 2018 GP Patient Survey showed patients satisfaction regarding access to the practice was statistically comparable with other practices; however, most indicators were below the CCG and national averages. Some comments on NHS choices and on the comment cards we received reported negative experiences.
• The practice took complaints and concerns seriously; however, they did not always respond to them appropriately to improve the quality of care. We found little evidence to show the practice reviewed complaints or ensured actions identified were completed or learning was shared with the whole practice team.

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

• The provider had not ensured care and treatment was provided in a safe way to patients.
• People were not adequately protected from avoidable harm and abuse.
• The provider was unable to assure themselves that people received effective care and treatment.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review the uptake of the national screening programme to encourage patients to attend their screening programmes.
• Review and improve the system to identify carers to ensure they receive appropriate support.
• Review the practice end of life care register to ensure patients are reviewed and removed from the list if appropriate.

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

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice