Archived: The Practice Loxford

Updated 5 May 2016

The Practice Loxford provides services to approximately 15,000 registered patients in the surrounding areas of Redbridge from a single site. It also provides a ‘walk-in’ primary care service primarily aimed at members of the public not registered with the practice. The practice sees around 260 patients per week on this basis. The service is provided through an Alternative Provider Medical Services contract. The practice is accessible to people with physical disabilities although the reception area does not have an induction loop.

The practice is owned by The Practice Surgeries Limited. The practice currently employs a team of salaried GPs (six whole time equivalent). The practice also contracts with ‘self employed’ GPs to provide regular sessions and one of these doctors focuses on services for older patients. The practice also employs a healthcare assistant, a practice manager and a team of receptionists, senior receptionists and administrators including a complaints liaison officer. The clinical team includes male and female doctors

The practice is located in a large primary and community health centre housing a number of health services. The building is purpose-built with good disability access. The property and premises are not owned or directly managed by The Practice Surgeries Limited.

The practice is currently contracted to provide the walk-in service from 8.00am to 8.00pm, seven days a week with pre-bookable appointments for registered patients available throughout the day. The practice has introduced an electronic appointment booking system and an electronic prescription service.

Out of hours primary care is contracted to a local out of hours care provider. The practice provides patients with information in the practice leaflet, on the website and by answerphone about how to access urgent care when the practice is closed. Patients are advised to ring “111” to access the out of hours primary care service.

The registered practice population is characterised by a high proportion of young adult patients aged between 20 and 39 years and children under 14. Eleven percent of registered patients are under 4 years of age compared to six percent nationally. In 2011/12, half of the practice population had a health condition limiting daily life which is in line with the English average of 49%. The local population is mobile, and culturally and ethnically diverse.

The practice is registered to provide the following regulatory activities: family planning; maternity and midwifery services; diagnostic and screening procedures; and treatment of disease, disorder or injury.

CQC previously inspected the practice in November 2013 with follow-up visits in March and April 2014. In our report of the inspection visits in 2014, the practice was found to be non-compliant with regulations relating to respecting and involving patients and assessing and monitoring the quality of service provision.

As a result, CQC imposed a ‘compliance action’ highlighting the lack of information provided in the reception area in languages other than English. The practice subsequently wrote to us outlining the action it had taken to improve this. We also issued a warning notice in relation to the continued failure of the provider to monitor and improve patient access to the service. The warning notice required the provider to achieve compliance with the relevant regulation by August 2014.

Updated 5 May 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Practice Loxford on 6 November 2015. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. But local clinical staff did not have regular meetings to learn from incidents and other safety information.

• The practice did not have systems in place to manage some key risks, for example in relation to repeat prescribing.

• Patients’ clinical needs were assessed and care was planned in line with national guidance. The practice had prioritised long-term care for improvement and had introduced condition-specific clinics, for example for diabetic care to improve patient outcomes.

• Patients we spoke with described doctors, nurses and reception staff as caring. However, the practice scored consistently below average in the 2015 national GP patient satisfaction survey for questions on care and patient involvement.

• The practice provided information about its services in the form of a practice leaflet and a website. Information about how to complain was available at the practice. The practice employed a complaints officer who met with patients as soon as they raised a concern and the practice had seen a reduction in complaints.

• Appointment systems were not working well. We spoke with patients who said they were queueing before 8.00am in the morning to make an appointment because of difficulty getting through on the telephone.

• The practice had suitable treatment facilities but some of the shared facilities such as the furniture and television screens in reception were damaged or not working and had been in this condition for months. The practice had raised issues with the relevant agencies but the problems had not been addressed.

• Staff told us they had access to the training they needed to develop in their role. Appraisals for non-clinical staff had recently been reintroduced.

• The practice had not addressed longstanding issues with quality and safety. The practice had not acted on some of the failures identified at our previous inspection of April 2014 and had not complied with a warning notice issued at that time.

The areas where the provider must make improvements are:

• The practice must ensure that facilities, including shared facilities used by their patients, are safe and take immediate action when a safety risk has been identified.

• Fire marshals must receive appropriate training. The practice must have sight of all relevant health and safety risk assessments and obtain assurance that any recommendations have been carried out by the responsible agency.

• The practice must ensure that repeat prescriptions are processed in line with its repeat prescribing policy and patients receive medicines on time.

• The practice must make sure the service is accessible to registered patients. The telephone appointment system must be fit for purpose.

• Local management arrangements must be sufficiently robust to ensure that safety and quality concerns are addressed without undue delay.

In addition the provider should:

• Provide regular opportunities for clinical staff to meet to discuss and review their practice, including significant events, safeguarding cases, learning and improvement.
• Review and monitor clinical staffing, skill mix and systems for routing patients to the most appropriate clinician to ensure that patient needs are being met in a safe and timely way.
• Carry out staff appraisals annually and provide structured opportunities for staff to review their performance with their manager.
• Explore ways of improving the patient experience. The practice was consistently scoring below average on indicators of compassionate care as measured by the 2015 national GP patient survey.
• Increase the information and support available for carers.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains 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 practice 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. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 5 May 2016

The practice is rated as inadequate for the care of people with long-term conditions.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, some examples of good practice for the care of people with long-term conditions.

• The practice had identified its management of long-term conditions as a priority and had improved its performance in this area as measured by the Quality and Outcomes Framework in 2014/15.
• The practice had a clinical lead GP for diabetes who had introduced a weekly diabetes clinic run with one of the nurses. The practice provided initiation of oral and insulin therapies The practice participated in integrated care management for patients with complex and multiple health conditions. The practice developed a care plan for these patients and the plans were discussed and updated through regular multidisciplinary meetings.
• The GPs discussed the care of patients with other health and social services professionals as appropriate. The practice benefited from being located in the same centre as several community health teams.
• The practice had systems in place to call patients with long-term conditions for regular review. We spoke with two patients with a long-term condition who confirmed they had a regular review with the GP and this included a review of their medicines.
• Longer appointments and home visits were available for patients with more complex conditions when needed.

Updated 5 May 2016

The practice is rated as inadequate for the care of families, children and young people.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, some examples of good practice for the care of families, children and young people.

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• There were systems 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.

• Immunisation rates were good for all standard childhood immunisations.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
• The practice offered weekly child health surveillance clinics and routinely screened new mothers for post-natal depression.
• The practice was open before and after school hours and at the weekends for walk-in appointments. However parents told us that they had difficulty booking appointments by telephone or in person when the practice opened at 8.00am because they had to get their children ready for school at this time.
• The premises were suitable for children and babies although some of the seating in the waiting area was hazardous with deeply ripped upholstery.

Updated 5 May 2016

The practice is rated as inadequate for the care of older people.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, some examples of good practice for the care of older people.

• The practice had appointed a long-term locum GP to focus on the care of older patients. This doctor carried out weekly visits to two large local nursing homes and ran an ‘Everyone Counts’ clinic for older patients, calling older patients on the patient list in for a health check including dementia screening, care planning, medicines review and lifestyle advice.

• Longer appointments and home visits were available for older people when needed.

• The practice told us they identified carers and provided patients who were carers with information about available support and relevant services. However, there was little evidence of this in the electronic patient records we reviewed. The practice manager told us that this was an area the practice intended to focus on over the coming 12 months.

• The percentage of patients aged 65 or over who had received a seasonal influenza vaccination in 2013/14 was low at 56% (compared to the national average of 73%).

Updated 5 May 2016

The practice is rated as inadequate for the care of working age people.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• The practice was open outside normal working hours and on the weekend for walk-in appointments. However patients who worked told us they found it difficult to access appointments. One patient who was queuing outside before the practice opened said they would be late for work and would then have to take further time out if they succeeded in making an appointment that day.
• Practice uptake rates for cervical screening (77%) were below the national average (82%).
• Breast cancer screening uptake rates (68%) were also below the national average (74%)
• The practice offered an online repeat prescription service and online appointments. Several patients told us the online appointment system was unreliable.

Updated 5 May 2016

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, some examples of good practice for the care of people whose circumstances may make them vulnerable.

• The practice held registers of patients living in vulnerable circumstances including those with a learning disability. The practice invited patients on the learning disability register for an annual health check.

• 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. The practice added ‘flags’ to the electronic patient records when patients were known to be at risk of abuse or were otherwise in vulnerable circumstances. The electronic records system has the facility to automatically alert staff when a patient with a ‘flag’ in their record contacts or attends the practice.
• The practice monitored A&E attendance and non-attendance of booked appointments.
• The practice had arrangements to allow people with no fixed address to register or be seen at the practice.
• A health advocate was located at the practice for one day a week to provide patients in vulnerable circumstances with further support.
• The practice had links with and could refer patients to ‘sister’ practices in the provider group providing specialist support for patients, for example, for refugees.

Updated 5 May 2016

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

The provider was rated as good for effective care overall and this includes for this population group. The provider was rated as inadequate for responsive care and for being well-led and requires improvement for safety and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were, however, some examples of good practice for the care of people whose circumstances may make them vulnerable.

• The practice held registers of patients living in vulnerable circumstances including those with a learning disability. The practice invited patients on the learning disability register for an annual health check.

• 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. The practice added ‘flags’ to the electronic patient records when patients were known to be at risk of abuse or were otherwise in vulnerable circumstances. The electronic records system has the facility to automatically alert staff when a patient with a ‘flag’ in their record contacts or attends the practice.
• The practice monitored A&E attendance and non-attendance of booked appointments.
• The practice had arrangements to allow people with no fixed address to register or be seen at the practice.
• A health advocate was located at the practice for one day a week to provide patients in vulnerable circumstances with further support.
• The practice had links with and could refer patients to ‘sister’ practices in the provider group providing specialist support for patients, for example, for refugees.