The intention of sharing the content of this report is to assist practices that have not yet been inspected. They can use the summarised version of the report to identify risk areas in their own practice, creating a suitable action plan to reduce the associated risk prior to inspection.
We understand how painful and damaging a CQC inadequate report is to practice and its team. If you have been personally affected by this report please get in touch. We will offer a listening ear.
If you need more formal support we would recommend the “Looking after you team”. They offer an non-judgmental coaching support service: https://www.england.nhs.uk/supporting-our-nhs-people/support-now/looking-after-you-confidential-coaching-and-support-for-the-primary-care-workforce/looking-after-you-too/
—————————————————————————————————————————————————————————–
https://www.cqc.org.uk/location/1-5468328360
Major area’s of risk identified in the CQC report:
Safeguarding:
The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse. Safeguarding registers were not in place to allow ease of identification of vulnerable at risk patients. Staff we spoke with told us they did not have a large number of vulnerable patients but could not tell us how many.
The safeguarding policy was not comprehensive or up to date. Staff who no longer worked at the practice were named and it did not cover female genital mutilation (FGM), modern day slavery, appropriate training levels for staff or reference the Intercollegiate guidance documents relating to Safeguarding Children and Young People.
Non-clinical staff had not undertaken training in safeguarding in line with Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff Fourth edition: January 2019. Training records sent to us by the provider showed 11 of 15 nonclinical staff were not trained to the appropriate level and 2 had no evidence of undertaking any training.
The practice did not have scheduled internal or multi-disciplinary safeguarding meetings in place. We were told any safeguarding concerns would be discussed at the internal practice meetings. However, staff told us regular meetings were not undertaken. We received 4 sets of meeting minutes, 2 from the last year, none of which had a set agenda or included a section on safeguarding .
Recruitment:
The provider had a memorandum of understanding with the Primary Care Network (PCN) in relation to staff employed by the PCN. However, the provider did not have evidence that PCN staff working within the practice had been subject to the appropriate recruitment checks prior to commencing employment and delivering care to their patients. This meant the provider could not assure themselves that patients were not at increased risk when receiving care.
Safety Systems and Records:
The provider was unable to locate their previous Health and Safety Risk Assessment. We were told since changes within the practice the management they did not know where it was filed. Health and safety, and fire risk assessments were undertaken on 11 November 2022, 2 days following our inspection. We received copies of the completed risk assessments with actions required. However, actions had not been addressed; we were told an action plan was in the process of being developed.
IPC:
Not all staff had completed effective training for infection prevention and control (IP&C). There was no evidence that 1 member of clinical staff and 2 members of non-clinical staff had ever completed any training. Two members of non-clinical staff and 1 member of clinical staffs’ training was out of date according to the provider’s training requirements.
The provider had an in date IP&C policy as a hard copy for staff to refer too, However, not all staff were aware of this, clinical staff told us they believed the IP&C policy was available online. This would mean staff would not be able to refer to the policy easily for guidance if required Whilst we saw evidence that some of the issues identified during the latest IP&C audit had been resolved, others had not.
For example, cleaning materials and instructions to clean the changing facilities for babies had not been introduced. We were told an action plan was in the process of being developed to support the audit.
The building appeared visibly clean with no evidence of dust. However, the fabric of the building had signs of wear and tear due to the age of the premises which included some bare exposed wood and areas of bare plaster showing.
Floor covering within the practice did not meet current IP&C guidance. We saw carpets in place and washable floor coverings which had not been appropriately sealed at the edges within rooms were clinical care was delivered. This would mean an increased risk of infection to patients.
The cleaner’s cupboard used to store cleaning equipment had non wipeable shelves in place and contained clean and sterile equipment for use in patient care. This would mean there was a risk of contamination of items prior to use, increasing the risk of infection to patients.
Equipment was stored on the floor of the sluice room meaning it would be difficult to clean the floor appropriately.
We requested copies of minutes from meetings since our previous inspection in November 2021 where IP&C had been discussed. We were provided with minutes of an IP&C meeting from May 2022, following the annual assurance visit from the local Clinical Commissioning Board where 3 members of staff were present. On review of the minutes of one staff meeting held in July 2022 the audit was mentioned but no detail documented as to findings. The provider could therefore not be assured all staff were aware of the outcome of the assurance visit and any issues highlighted.
Risks to patients:
The use of locum staff and payment of overtime to staff had been used to manage staff absences.
However, we were told that this had recently been limited due to financial constraints and staff told us they were working over their contracted hours unpaid to provide cover and complete essential work.
The provider had an appropriate range of equipment and emergency protocols in place to respond to medical emergencies. However not all staff were suitably trained in emergency procedures. For example, there were 24 staff working at the practice and data showed 15 staff had not completed anaphylaxis training, 8 had not completed sepsis training, 10 had not completed adult life support training and 15 had not completed Pediatric Life Support training. The training gaps would mean staff may not have the skills and knowledge to identify and manage an emergency situation. This increases the risk of poor outcomes for patients.
Appropriate and safe use of medicines
The practice could demonstrate the prescribing competence of non-medical prescribers, and there was regular review of their prescribing practice. However, this was not supported by clinical supervision or peer review.
The provider was not able to demonstrate that it remained safe to prescribe medicines to patients where specific, frequent, monitoring was required in all cases.
There were 155 patients taking direct oral anticoagulants (DOACs), a medicine to prevent thrombosis. Review of patients’ records showed that 104 patients had not had a creatine clearance calculated, following a blood test to monitor kidney function recorded in their records to ensure medication was prescribed at a safe level. The clinical search also identified 4 patients were overdue blood tests.
There were 38 patients taking a medicine for high blood pressure which can alter the potassium levels and pose a risk to a patient’s health. Review of the patient records showed 13 patients had not received appropriate 6 monthly blood testing. However, they had all been monitored within the previous 12 months.
Track record on safety and lessons learned and improvements made:
Staff told us how they would identify, escalate and report any concerns, safety incidents and near misses verbally or using a paper based form. However, staff told us there was an IT based incident reporting system, but they were not able to use this as they had not received training to use the system.
We were told significant events would be discussed and learning disseminated at practice and staff meetings .
We saw evidence that 3 significant events (SEA) were discussed at a clinical meeting in May 2022 but we saw no evidence that the 2 remaining SEAs had been discussed or shared with staff.
Staff told us they had a meeting each morning to discuss practical events relating to that day’s work, for example staffing , on call GP etc. but this forum was not used to share learning, there was not always a GP present and minutes were not taken.
Safety Alerts:
The provider was unable to demonstrate that all relevant safety alerts had been responded to and repeated periodically to identify any new patients to the practice who may require review.
Effective needs assessment, care and treatment:
The practice had some systems and processes to keep clinicians up to date with current evidence based practice. However, the system in use for receipt, dissemination and actions relating to safety 11 alerts was ineffective at the time of our inspection. This had led to patients not receiving appropriate review and potential changes to their care and treatment.
Patients’ treatment was not always reviewed and updated in line with current standards. Patients suffering from long term conditions did not always receive an appropriate health review.
Review of the clinical system identified 33 patients coded as suffering from a mental health disorder, none of which had any physical or mental health reviews undertaken. Therefore, the provider could not be assured patients with poor mental health, including dementia, were referred to appropriate services and receiving appropriate care.
Monitoring care and treatment:
The provider did not have a programme of targeted quality improvements in place. There was no system in place to review unplanned and readmissions to secondary care. The provider told us they did not have receive or request data to show hospital admission rates for their patients to review actions required.
The provider cared for patients within 2 local care homes and initial call outs to review any patients were undertaken the Home Care Team put in place by the Primary Care Network (PCN). The Home Care Team consisted of registered nurses working at advanced level. We were told the provider did not get feedback from the team if they carried out a visit unless they needed the assistance of a doctor from the practice. Therefore, this meant the provider was not always aware of the patients’ needs, outcomes and care required in a timely way.
Effective staffing:
The practice had a programme of essential learning. However, review of the essential training completion showed significant gaps when reviewed against the provider’s training matrix. This means the provider could not be assured staff had up to date knowledge in all areas they deemed essential to ensure safe patient care.
Staff told us they did not get protected learning time to complete mandatory training and due to the activity within the practice they were unable to complete the required training. However, clinical staff told us they could access conferences and book external off site training if required.
Managers told us that as a result of the Covid pandemic and their commitment to delivering Covid vaccinations with the primary care network, staff appraisals had been put on hold. This had been commonplace across the CCG. However, we did see evidence that all appraisals that were due had been scheduled. We were told one to ones, coaching and mentoring and clinical supervision were not undertaken.
A formalised audit program was in place and completed by the GP partner for the employed advanced nurse practitioner and clinical pharmacist working in the practice who was employed by the PCN to provide assurance of competence relating to prescribing practice. However, audit of consultations and outcomes were not undertaken.
Leadership capacity and capability:
At the time of our inspection the provider was undergoing a period of significant financial challenge, the extent of which the management had been not fully aware of until highlighted by changes within the practice. The financial issues had meant providing sufficient staff and supplies to deliver safe and effective care to patients had become a risk. Managers had partially mitigated the immediate risks to patient care with support from the local Integrated Care Board (ICB). However, the provider and the ICB were aware a longer term solution was required. The provider was in the process of exploring options on how to provide a secure and stable future for the practice, its patients and staff. The provider had no plans in place for the future leadership of the practice. The provider told us this would be part of the longer term solution being looked at jointly with the ICB. Staff at all levels told us they were very short staffed, which resulted in excessive demands and meant staff routinely worked over their contracted hours without pay or time back. Staff feedback indicated that generally managers and leaders were always available if they needed to approach them for assistance. However, all staff told us communication needed to be improved with more face to face meetings and personal interaction.
Vision and strategy:
The practice did not have vision, values and strategy in place. Staff we spoke with confirmed they were unaware of any future vision for the practice.
Culture:
Staff we spoke with told us the practice did not have any identified vision or values, processes to manage behavior inconsistent with expectations.
We were told some of the staff would not complete the training identified as essential in the provider’s policies as they felt this was not required for their role. Managers had not given staff protected learning time or ensured that staff completed essential training.
Staff we spoke with told us they felt supported by the practice manager and described good teamwork. However, the demands of the work had increased with an ongoing shortage of staff. Overtime payments to provide extra cover and clinics had been minimized and locum usage had reduced.
Staff told us they regularly worked extra hours and completed essential training outside working hours with no payments. Staff told us this had affected their wellbeing due to increased pressure to provide safe care.
A Freedom to Speak Up Guardian had been identified but not all staff were aware of this and staff who were did not all know who this was.
Staff had not all undertaken equality and diversity training. Review of training records showed 9 of the 24 staff currently working had not completed equality and diversity training as set out as required in the provider’s training matrix.
Governance arrangements:
Governance systems and process had not been developed or embedded to support the safe delivery of patient care and demonstrate clear oversight of patients and staff needs.
The practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately The provider did not demonstrate a thorough oversight of issues and challenges facing the practice and was unaware of all systems and processes in place.
For example,
• Whilst essential staff training was monitored, the processes failed to ensure completion by staff.
• A lack of systems and process relating to numerous aspects of safeguarding meant vulnerable patients may be at risk of harm.
• The process for the management of safety alerts was not effective and had led to safety alerts not being actioned.
• The management of patients on high risk medicines and management of patients with long term conditions was not always effective,
• The provider had insight to some of the financial challenges facing the practice. However, they were unaware of the depth of the financial issues prior to them being identified following changes within the practice.
• There were no systems or process in place to ensure appropriate governance and oversight of the risks facing the practice. The provider told us they were unaware of how risks were managed for the practice.
• Clinical staff told us the regularly work above there contracted hours without pay, managers were not aware of this until we told them.
Information sent to us by the provider indicated a lack of internal management meetings. The provider told us practice meetings should occur every 3 months. We saw meeting minutes from 2 practice meetings undertaken in the previous 12 months with the last 1 in July 2022. Staff we spoke with confirmed no other practice meetings had taken place and no further meeting was scheduled.
We received meeting minutes for 2 departmental meetings, 1 clinical nurse meeting and 1 reception staff meeting since our previous inspection in October 2021. The minutes did not include information related to the overall governance of the practice. For example, infection prevention and control, health and safety, significant events and complaints were not included. The meeting minutes we reviewed did not evidence the use of set agenda items to ensure all the expected aspects of effective governance was discussed regularly. The provider could not be assured staff were aware of all issues, concerns and requirements related to governance to support safe care.
Staff we spoke with told us they were aware of some financial issues affecting the practice and lack of communication from the managers made them uncertain of their future roles and responsibilities.
The provider did not have a system and process in place to ensure policies and procedures were regularly reviewed and updated. There was no document control process in use, not all policies were dated and whilst some had been reviewed not all the information included was correct. The provider sent us a Training Matrix and a Staff Development Policy both of which indicted different expectations of what training should be undertaken. For example, differences included how often staff should undertake fire, equality and diversity, Mental Capacitary Act and Deprivation of Liberty Safeguard ( DoLS), sepsis, whistleblowing and prevent radicalization training. The Staff Development Policy did not identify the requirement of a variety of training including in consent, display screen equipment, general data protection regulation (GDPR), chaperone and bullying and harassment.
Managing risks, issues and performance:
The provider did not have systems and processes in place to identify, manage, mitigate and review risks associated with the practice which may impact on patient care. Managers told us during our site visit, and confirmed by email, they were unaware of how the risks to the practice were identified, recorded and reviewed.
There was no process in place to ensure required risk assessment were undertaken in a timely way. The provider was unable to provide us with legionella and health and safety risk assessments When considering service developments or changes, the impact on quality and sustainability was not always taken into account.
The current financial constraints at the practice had impacted on care delivery. For example, staff told us Saturday flu vaccination clinics usually in place from late October had not been started until mid-November due to constraints on the overtime payments required to deliver the service. Staff we spoke with told us the nurse afternoon clinics had been utilised to deliver flu vaccinations but that this had impacted on appointment availability.
Engagement with patients, the public, staff and external partners:
Although the practice had gathered patients’ feedback through the Friends and Family survey there was no evidence to show that this data had been considered to improve services and culture. The provider told us they had reviewed the national patient survey to look at areas of improvement required but had not formulated an action plan on how improvements would be identified, managed and effectivity measured. The practice informed us there had been a Patient Participation Group (PPG) which had not been active for some time. However, the chairman and secretary of PPG had recently resigned. The practice told us they were in discussion with the remaining PPG members to review a way forward. Staff we spoke with told us they would be able to voice their views and would be listened to but not all felt these views would be reflected in the planning and delivery of services. The provider worked with other practices within the PCN to build a shared view of challenges and of the needs of the population from the GPs involved. However, there was no evidence of interaction with other stakeholders, including patients, carers and any local organisations.
Continuous improvement and innovation:
The provider was unable to demonstrate they had a comprehensive plan for continuous learning and improvement or quality improvement in place. Managers attended meetings of the Primary Care Network (PCN) where discussions and plans relating to PCN development were undertaken. However, the provider could not demonstrate a focus on continuous learning and improvements within the practice. Staff did not get protected learning time, lack of meetings evidencing shared learning meant not all staff were aware of all the concerns and issues relating to the service. Failure to appropriately manage risks did not allow continuous improvements to the service.