Highland Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Highland Medical Practice on 10 February 2015. As a result of our findings during that visit the provider was rated as requires improvement for providing safe, effective, and well-led, and it was rated as requires improvement overall. The full comprehensive inspection report from that visit was published on 30 July 2015 and can be read by selecting the ‘all reports’ link for Highland Medical Practice on our website at www.cqc.org.uk.

The practice submitted an action plan to tell us what they would do to make improvements and meet the legal requirements. We undertook an announced comprehensive follow-up inspection on 10 January 2017 to check that the provider had followed their plan, and to confirm that they had met the legal requirements. The provider expressed a willingness to improve but had not addressed core issues which could improve the quality, safety, and effectiveness of the service. As a result of our findings during that visit the provider was rated as requires improvement for providing safe, effective, caring and inadequate for well-led care. The full follow up report was published on 28 April 2017 and can be found by selecting the ‘all reports’ link Highland Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 11 October 2017. Overall the practice remains rated as requires improvement.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Many issues raised at the last inspection had been addressed for example, all staff were appropriately immunised. Policies including safeguarding and chaperoning had been reviewed. Notices were displayed at the main site and branch regarding chaperoning.
• The practice had a hearing loop and provided an interpretation service for patients whose first language was not English.
• All staff were up to date with role specific training, including basic life support, fire, infection control, information governance, safeguarding adult and children.
• The practice had improved identification of carers from the last inspection from 0.4% to 2%.
• The practice did not have clearly defined and embedded systems to minimise risks to patient safety. For example the practice did not have an effective system in place for recalling patients taking high risk medicines; this was raised at the last inspection. In the action plan submitted the practice said they would search their system and monitor patients.
• Prescriptions were stored securely; however, on the day of inspection we noted prescriptions were not tracked through the practice.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Results from the national GP patient survey showed that patients rated the service below average for several aspects of consultations with nurses and GPs. They were rated above average for several aspects of access to the service and satisfaction with receptionists.

• The practice conducted their own patient survey in September 2017 which showed that patients rated the practice as good for consultations with nurses and GPs.

• Information about services and how to complain was available.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had an effective Patient Participation Group and meetings showed how the practice had listened and responded to patient feedback.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences. Supports patients to make, or participate in making, decisions relating to the service user’s care or treatment to the maximum extent possible by reviewing GP patient results to improve patient care in relation to consultations with nurses and GPs.

• Ensure care and treatment is provided in a safe way to patients

In addition the provider should:

• Consider implementing palliative care and nurse meetings.

• Handle all blank prescriptions in accordance with national guidance and tracked accordingly.

• Consider installing a bell at the main site for patients with accessibility problems.

• Continue to review patient outcomes in relation to quality improvement (for example clinical audits).

• Review temperature monitoring on the vaccine fridge at the branch site so it meets current guidance.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Highland Medical Practice’s main site (previously registered with the Care Quality Commission (CQC) as Dr Gnanachelvan & Partners) on 10 February 2015. As a result of our findings during that visit the provider was rated as requires improvement for providing safe, effective and well-led care, and it was rated as requires improvement overall. The full comprehensive inspection report from that visit was published on 30 July 2015 and can be read by selecting the ‘all reports’ link for Highland Medical Practice on our website at https://www.cqc.org.uk/location/1-549056430.

During that visit our key findings were as follows:

• The provider had not clearly documented discussions and learning from significant events.

• There were ineffective systems for assessing, monitoring and improving the quality and safety of the services provided.

• The provider had not adequately assessed or managed risks to service users.

• Several staff had not received key training, there were no records of appraisals for some staff, and inductions had not been documented for new staff.

• Performance for cervical screening was below the national average.

• Results from the national GP patient survey showed that patients rated the practice below average for some consultations with GPs and nurses.

• Appropriate recruitment checks had not been conducted and documented.

• Some policies were not fit for purpose and not all staff were aware of the whistleblowing policy.

This inspection on 10 January 2017 was conducted as an announced comprehensive inspection of the provider’s main and branch sites to assess whether the provider had followed their action plan and was meeting the requirements. The provider expressed a willingness to improve but had not addressed core issues which could improve the quality and safety of the service; we found that they had not made sufficient improvements in the 18 months between publication of their report in 2015 and this inspection. Our key findings across all the areas we inspected in January 2017 are as follows:

• There was an open and transparent approach to safety but there was no effective system in place for reporting, recording and sharing significant events within the practice. The provider received safety alerts but did not have an effective system in place for ensuring that they were actioned.

• Risks to patients and other service users, such as those related to health and safety, immunisation of staff, handling of hazardous waste, blind cords in a waiting area, recruitment checks, and the availability of emergency medicines at both sites had not been assessed or well-managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance; however, there was no programme of quality improvement (for example clinical audits). Data from the Quality and Outcomes Framework (QOF) and other targets showed that the provider was a negative outlier for exception reporting for some health indicators when compared to local and national averages. They did not demonstrate any action plan in place to address performance in these areas.

• The provider was a positive outlier for QOF health indicators related to dementia, asthma, hypertension and chronic obstructive pulmonary disease and they had received an award from Public Health Bromley in May 2016 for achieving one of the highest Chlamydia screening rates in Bromley borough.

• There were no Patient Group Directions (PGDs) in place for two nurses who administered vaccines, and PGDs for another nurse had not been authorised in line with current legislation.

• The provider did not have an effective system in place for regularly monitoring patients taking disease-modifying antirheumatic medicines.

• The majority of staff were aware of their roles and responsibilities; however, we identified instances where some staff were not following the practice’s policies.

• The provider had a number of policies and procedures to govern activity and held regular governance meetings; however, some policies needed to be updated.

• The majority of staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment; however, we were not provided with evidence of basic life support or fire safety training for a member of administrative staff.

• The provider had vicarious liability insurance in place for the practice, but did not provide us with evidence to demonstrate any medical indemnity insurance in place for a nurse; they addressed this shortly after the inspection.

• Results from the national GP patient survey showed that patients rated the service below average for several aspects of consultations with nurses and GPs. They were rated above average for several aspects of access to the service and satisfaction with receptionists.

• Information about services and how to complain was available and easy to understand, with the exception of avenues of carer support which were not advertised at the branch site. Carer identification was low. The provider made improvements to the quality of care as a result of complaints they received.

• Staff told us the provider did not offer interpreter services and they relied on staff and patients’ family members to translate information at consultations. There was no hearing loop for patients with hearing difficulties.

• Although we observed that reception staff maintained patient and information confidentiality, conversations in the nurse’s room at the main site could easily be overheard in the consulting room next to it.

• The provider had not appropriately documented various processes.

• The provider was experiencing a change in its leadership structure. At the time of our inspection there was no practice manager in place and we found that there were deficiencies in some of the provider’s governance systems and processes. However, staff felt supported by the GP partners.

There are areas where the provider needs to make improvements. Importantly, they must:

• Enable and support all service users to make, or participate in making, decisions relating to their care or treatment to the maximum extent possible. Specifically, improve accessibility for patients with language barriers.

• Ensure effective and sustainable clinical governance systems and processes are implemented to assess, monitor and improve the quality of the services provided, and implement an effective strategy to ensure the delivery of high quality care. This includes establishing a programme of audits including clinical audits, and implementing actions to improve patient satisfaction and outcomes for patients in relation to cervical screening and childhood immunisation. Additionally, ensure there are appropriate policies to enable staff to carry out their roles, practice policies are being followed, relevant records for persons employed are obtained, and all records pertaining to the running of the service are suitably maintained.

• Assess, mitigate and monitor risks to the health and safety of service users and others that may be at risk, Additionally, ensure the proper and safe management of medical equipment and medicines; this includes ensuring that medicines and equipment are available in sufficient quantities and are fit for use.

In addition the provider should:

• Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

• Review the need to improve accessibility for patients, particularly in relation to those with hearing difficulties.

• Ensure all staff are up to date with training.

• Improve patient privacy and confidentiality at the main site.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by the CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice