Park View Medical Centre

We carried out an announced focused inspection at Park View Medical Centre on 15 July 2019 following our annual review of the information available to us. The inspection looked at the following key questions: Safe, Effective and Well-led.

Following our inspection on 15 July 2019, we rated the practice inadequate overall and also for the Safe, Effective and Well-led key questions. We did not specifically inspect the Caring or Responsive key questions and the ratings therefore remained unchanged based on the findings from the last inspection in June 2015. The inspection report can be found by selecting the ‘all reports’ link for Park View Medical Centre on our website at

We issued a warning notice for breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe Care and Treatment and Good Governance).

This inspection was an announced focused inspection undertaken on 11 November 2019 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches identified within the warning notice.

At this inspection we found:

• A range of policies, procedures and/or protocols had been developed in relation to the management of medicines, patient safety medicines alerts, exception reporting and prescription security to provide guidance to clinicians and staff.
• Monitoring of Methotrexate, Azothiaprine and Lithium (high risk medicines) was up-to-date.
• Action had been taken in response to a medicines safety alert for Hydrochlorothiazide. However, other alerts had not always been received, logged and/or appropriately acted upon by the practice.
• Some patients with long-term conditions were still being issued with medication despite monitoring being overdue.
• Systems had been established to record incoming and outgoing prescription numbers and to ensure the safe storage of prescription stationery stock.
• A five-year fixed electrical wiring certificate had been obtained for the premises which confirmed the installation was satisfactory.
• An up-to-date minor surgery audit had been completed for the period 1/08/2018 to 31/07/2019.

At our previous inspection on 15 July 2019, we rated the practice as inadequate and placed the service into special measures. As per our published inspection methodology, a further full comprehensive inspection visit will be carried out within six months of the publication date of the inspection report, to monitor the work the practice has started to produce the required improvements to the service.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We last inspected this service on 17th June 2015. It was then rated as good overall and good for the five key questions of safe, effective, caring, responsive and well-led.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well-led. We did not specifically inspect the caring or responsive key questions and the ratings therefore remain unchanged based on the findings from the last inspection in June 2015.

We based our judgement of the quality of care at this service 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 rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have appropriate systems in place for the safe management of medicines prescribed to patients.
• Blank prescription paper was not kept securely and its use was not monitored in line with national guidance.

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

• Medication and long-term condition reviews were not effectively coordinated. There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Some performance data was below local and national averages.
• There was a lack of quality improvement.

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

• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• While the practice had a clear vision, that vision was not supported by a credible strategy.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.

These areas affected all population groups so we rated all population groups as requires improvement.

At the last inspection the practice was rated as good for providing Caring and Responsive services. These areas were not re-inspected on this occasion and the ratings therefore remain unchanged.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Provide non-clinical staff with Sepsis awareness training.
• Support all staff to complete Equality and Diversity Training.
• Develop a Duty of Candour Policy.
• Ensure alerts are placed on records to identify patients as vulnerable or subject to a safeguarding concern.
• Maintain a log of stocks of immunisations and vaccinations.
• Ensure all the necessary recruitment records are in place for staff.

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.

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.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care