Archived: Minehead Medical Centre Also known as Harley House

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We have rated the practice as Inadequate for providing effective services because: The practice did not have appropriate systems to identify patients requiring ongoing monitoring of their care and treatment, including patients diagnosed with asthma and hypothyroidism. The practice was unable to demonstrate that they had assessed staff to ensure they were acting in their competencies. The practice were unable to demonstrate that staff were up to date with training they identified as mandatory. The practice had not identified actions to improve uptake of national screening and immunisation programmes. There was no process to systematically review Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) to ensure decisions were made in line with guidance and remained relevant to the patient’s wishes.

This service scored 0 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Practice staff were unable to provide assurance that there was a clear process to ensure housebound patients received a review of their care and treatment. Staff did not have access to a formalised process to ensure patients were identified and managed consistently. The practice sent us evidence to demonstrate they had oversight of these patients, however the information provided was not complete as it did not include all relevant patients. The practice was unable to demonstrate that care for their most clinically vulnerable patients was prioritised. For example: Practice leaders were unable to provide assurance that they were aware of how many patients were overdue a review of their care and treatment. Systems had not been implemented to ensure patients with the most urgent needs were prioritised. We identified a 2-day delay in a home visit being conducted for a patient with a red swollen leg. There was no documented rationale for this delay and the patient was later diagnosed with deep vein thrombosis (blood clot in the body) which, if not treated promptly can be life threatening.

At our inspection in November 2022, we found: Systems were not embedded to ensure all patients requiring a review of their care and treatment were identified and recalled as necessary. Housebound patients did not always receive a review of their care and treatment. There was a backlog of approximately 1800 unfiled documents. At this inspection we found: The practice was unable to provide assurances that all patients requiring a review of their care and treatment had been identified and recalled as necessary. The practice told us that staff responsible for managing patient recalls were not in work and so there was backlog. We requested evidence to demonstrate which patients still required reviews of their care and treatment, however the information provided was not comprehensive and did not demonstrate the practice had effective oversight. At the time of inspection there was no documented protocol for annual reviews to ensure processes to identify and invite patients in for a review were consistent. Our review of clinical records identified all patients had not been routinely invited in for a review of their care and treatment including patients diagnosed with asthma and hypothyroidism. The document backlog had increased to approximately 5000 unfiled documents. The practice had not introduced processes to ensure the most urgent documents were prioritised which meant changes to patients’ care and treatment were not being actioned as required. For example, a request from secondary care had requested 2 medicines prescribed to slow the heart rate were stopped for a patient who had been admitted for complete heart block. This was requested on 11 October 2023 and had not been actioned by the practice until the week prior to inspection.

Feedback from staff indicated that there were not consistent processes to ensure staff delivered evidence-based care and treatment. Non-medical prescribers had daily access to a supervising GP and were able to raise any queries they had about a patient’s treatment. However, these interactions were driven by the non-medical prescribers with emphasis on them raising concerns or areas for development with the supervising GP. This meant that if they were unaware of knowledge gaps, these areas would not be raised and discussed.

The practice did not have necessary processes to ensure all patients received appropriate care and treatment. For example: We reviewed 5 patients diagnosed with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months for acute exacerbations of their condition. We found that not all patients were prescribed these medicines with appropriate clinical rationale or assessment being documented. Patients did not always receive a follow up in line with best practice guidance to determine the effectiveness of the medicine. We reviewed 4 patients diagnosed with hypothyroidism who were overdue necessary monitoring. For all 4 patients, there was no evidence to demonstrate that the practice had identified these patients were overdue monitoring and had taken steps to address this. There was also no evidence to demonstrate clinicians issuing prescriptions of their medicines had checked that required monitoring was up to date or taken steps to invite them in for a review.

Practice leaders told us that they were aware of resource shortages at the local minor injuries unit. However, this information had not been considered when patients were directed to use this service as part of the practice’s triage process and when appointment availability had reached capacity.

Information received from other local services included that patients of Minehead Medical Centre had been inappropriately directed to use their service by the practice.

Due to the backlog of documents and patient notes which required summarising, the practice was unable to demonstrate that; Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved. Patients received consistent, coordinated, person-centred care when they moved between services.

The practice was unable to demonstrate that their management of wound care was effective. We were told that an audit on wound care had been conducted but outcomes had not been shared. The practice was unable to demonstrate that they had necessary processes to meet the needs of patients requiring this service. No analysis had been conducted to identify the number of appointments necessary to ensure patients had access to services for their wound care. Staff told us they would squeeze patients into full clinics. The practice had support one day a week from a social prescriber employed by the primary care network.

The percentage of persons eligible for cervical cancer screening at a given point in time who were screen adequately within a specified period (within 3.5 years for persons aged 25 to 49, and within 5.5 years for persons aged 50 to 64) was 70.5%. This was below the national target of 80%.

The practice had not identified processes to improve uptake of cervical screening. They did not offer extended hours for working age women to attend the practice. The earliest appointment available was 8.30am. Staff told us that an audit on wound care had been conducted but outcomes and any learning had not been shared.

The practice did not have processes to systematically review DNACPR/TEP forms to ensure they remained up to date and in line with patient's wishes. (Do Not Attempt Resuscitation is a medical order which means if your heart or breathing stops your healthcare team will not try to restart it.) (Treatment Escalation Form is a form demonstrating a patients wishes should they become seriously unwell.) We reviewed 4 patients with a DNACPR or TEPs in their records. These forms had been completed at the point of admission by A&E however they had not been reviewed by the practice following the patient’s discharge. An incident had occurred where the practice had made a best-interest decision to transfer a registered patient to hospital in contradiction to the information in their TEP form. We discussed this with the practice who advised that the TEP form had not been updated in 6 years and the circumstances surrounding the incident confirmed this decision to be in the best interest of the patient. However, this incident did not prompt the practice into implementing a systematic review of DNACPR/TEP forms. The practice advised that they did not have the resources to support this piece of work.