Archived: Iwade Health Centre

Updated 18 October 2017

Iwade Health Centre is located in a semi-rural residential location in the village of Iwade in Kent and provides primary medical services to approximately 6,000 patients. Iwade Health Centre holds an Alternative Provider Medical Services (APMS) contract. The practice is housed in a purpose built building, with consulting and treatment rooms based on the ground floor and administration and meeting/training rooms on the first floor. There are parking facilities and the building is accessible for patients with mobility issues and those with babies/young children.

The practice patient population includes more younger patients from 0-14 years than the England average age distribution, less 14 to 29 year old patients, more 30 to 49 year old patients and significantly less older people. It is situated in an area where the population is considered to be less deprived.

The provider for the practice is Malling Health Ltd which is an organisation with multiple locations, and the service is provided by a number of locum GP’s. On the day of the inspection a lead locum GP had been employed by the practice for a three or four month period to work four days each week, there was a salaried GP one day each week from a separate Malling Health (UK) Ltd practice and other locum GPs were employed to cover Friday. The practice employs a number of locum practice nurses as well as a permanent health care assistant. There is a practice management team and reception/administration staff.

The practice is open from Monday to Friday between 8.00am and 6.30pm. In addition to appointments that can be booked up to four weeks in advance, urgent on the day appointments are available for people that need them. Appointments can be booked over the telephone or in person at the practice. There are arrangements with other out of hour’s providers to deliver services to patients outside of the practice’s working hours.

Services are provided from:

1 Monins Road, Iwade, Sittingbourne, Kent , ME9 8TY

The practice had been inspected previously in February 2015 and was found to be complaint with the Health and Social Care Act 2008, being rated good overall and in all domains. A responsive comprehensive inspection was conducted at the practice on 6 June 2017 in response to complaints and concerns raised with the Care Quality Commission. The practice was rated as inadequate overall and in the safe, effective and well-led domains. It was rated as requires improvement for the responsive domain and good for caring.

Updated 18 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Iwade Health Centre on 6 June 2017. Overall the practice is rated as inadequate and urgent conditions have been placed on the providers registration which include: the restriction of new patients being registered; an urgent review of patient demand to determine the correct level of service provision and resource; the implementation of a sustainable system to ensure repeat prescription requests, medication reviews and correspondence are reviewed and actioned without delay and ensuring capable and sufficient staffing at the practice to deliver a safe service.

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

• The approach to investigating and reviewing significant events was insufficient. There was no evidence of learning from events or action taken to improve safety.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was no system for ensuring patient safety information was appropriately shared and acted upon.
• The practice were not able to provide documents or a training schedule to show who had received training. This included basic life support, safeguarding children and vulnerable adults relevant to their role and competence based training.
• The practice did not have a system to ensure staff who acted as chaperones were trained for the role or had received a Disclosure and Barring Service (DBS) check.
• An annual infection prevention control audit had been completed. However there were no records to show that action had been taken to address improvements identified as a result
• There were insufficient systems to ensure the safe prescribing and management of medicines, which included the review of high risk medicines and prescription pads were not monitored throughout the practice.
• Appropriate recruitment checks had not been undertaken prior to staff being employed
• Risk assessments regarding health and safety, fire safety COSHH and legionella had not been carried out or had not been actioned.
• The practice had achieved 96% of the total number of QOF points available.
• Although some single cycle audits had been carried out, we saw no evidence that these were informing and improving patient outcomes.
• Basic care and treatment requirements were not met. For example, there was an insufficient system to review patients regarding their medicine.
• The information needed to plan and deliver care and treatment was not available to relevant staff in a timely and accessible way.
• Multi-disciplinary meetings were not taking place.
• The majority of patients who responded to the national GP patient survey (2016) said they were treated with compassion, dignity and respect. However, patients spoken with reported a lack of continuity in their care due to the use of different locum GPs and nurses.
• There was no system to offer support to patients who identified themselves as carers.
• Information about how to complain was available to patients; however there was no evidence of learning being shared to mitigate further risk.
• Urgent appointments were usually available on the day they were requested.
• There was no clear division between the local and the corporate leadership structure and staff told us they were unsure where responsibility for governance lay.
• The most recent patient participation group meeting minutes were from 2015.

The areas where the provider must make improvements are:

• Ensure that sufficient numbers of suitably qualified, competent, skilled and experienced clinical staff members are deployed.

• Ensure systems and process to assess, monitor, manage and mitigate risks to the health and safety of patients who use services are in place.

• Introduce effective systems or processes to identify, report, record and act on and significant events, incidents and near misses.
• Ensure staff have the qualifications, competence, skills and experience to provide safe care and treatment, including safeguarding adults and children at the appropriate level and basic life support training.
• Ensure the proper and safe management of medicines.
• Establish and operate effective recruitment procedures to ensure that fit and proper persons are employed.
• Establish an appropriate system to ensure that the information needed to plan and deliver care and treatment is made available to relevant staff in a timely and accessible way.
• Ensure that people employed by the service receive training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
• Introduce effective systems to assess, monitor and improve the quality and safety of the services provided.

The areas where the provider should make improvement are:

• Review the recommendations made in the fire risk assessment are actioned and that fire evacuation procedures are rehearsed.
• Review the process for offering support to patients identified as carers.
• Review the process to alert the GP that a home visit request has been received.
• Improve the accessibility of the service.
• Review and update procedures and guidance.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 August 2017

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

• Longer appointments and home visits were available when patients needed them or when required.
• The practice relied on locum clinical staff including GPs and nurses. There was no named GP on site for this patient group.
• Structured annual reviews were not undertaken to check that patients’ health and care needs were being met.
• There was no evidence that nurses carrying out reviews for patients with long term conditions had received specific training to do so.
• The practice could not demonstrate that they worked with relevant health and care professionals to deliver a multidisciplinary package of care to patients with the most complex needs.

Updated 10 August 2017

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

• The practice could not demonstrate that staff had completed training in safeguarding children.
• There were no systems to follow up where children did not attend their appointment.
• There were no systems to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk.

• The practice could not demonstrate role-specific training, for example, for nurse immunising children and babies.

• Immunisation uptake rates were highlighted as a negative variation within CQC data and relatively low for a number of the standard childhood immunisations. For example, the percentage of children aged two who had been immunised with pneumococcal conjugate booster vaccine was 73% against the national target of 90%.
• The premises were suitable for this population group.

Updated 10 August 2017

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

• The practice could not demonstrate that staff had completed training in safeguarding adults.
• We saw evidence which showed that basic care and treatment requirements were not met. For example, three urgent prescriptions for patients resident in a care home had not been actioned after seven days.
• The practice were not able to demonstrate that there was a system to ensure medicine reviews were carried out as required, including where medicine relied on accuracy of blood tests to determine the safe amount prescribed.
• The care of older patients was not managed in a holistic way, as multi-disciplinary meetings were not being conducted at the practice.
• The practice had a register of older patients who were approaching the end of life; however this information was not co-ordinated with other health and social care professionals.
• The practice offered home visits for patients who were unable to attend the practice.

Updated 10 August 2017

The practice is rated as inadequate for the care of working age people (including those recently retired and students).

• The percentage of respondents to the GP patient survey who were 'very satisfied' or 'fairly satisfied' with their GP practice's opening hours was highlighted as a negative variation in CQC data. 55% of respondents said they were very or fairly satisfied compared to the CCG average of 72% and the national average of 76%.

• Appointments could be made on-line, on the telephone or by person.

• The practice was difficult to access by telephone. For example, 49% of respondents to the national GP patient survey said they could get through easily to the practice by phone compared with the clinical commissioning group (CCG) average of 64% and the national average of 73%.

• There were no early or extended opening hours for patients who worked or students.
• Health checks were available, if requested.

Updated 10 August 2017

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 68% compared to the CCG average of 93% and the national average of 89%.
• The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months was 74% compared to the CCG average of 83% and the national average of 84%.
• The practice had not worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.
• Medication reviews were not consistently conducted for patients on high risk medicines.
• We reviewed the care of two patients living with mental health conditions and found that their care had not been reviewed since 2014.
• The practice did not have a system to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.
• The practice were unable to demonstrate that they followed up or provided after care to a patient sectioned under the Mental Health Act in 2016.

Updated 10 August 2017

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

• The practice were not able to demonstrate that staff had been trained to recognise the signs of abuse in vulnerable adults and children.

• The safeguarding policy was out of date and did not provide appropriate information for staff.
• The practice had not worked with multi-disciplinary teams in the case management of vulnerable patients.
• The practice provided longer appointments for patients living with a learning disability. These patients were not flagged on the system to alert administrative staff to their needs.
• The practice had a register of 33 patients who were living with learning disabilities. A random selection of five of these patients was made and none of these had received an annual review.
• The practice did not identify those whose circumstances may make them vulnerable who were approaching the end of life.