All inspections: Lees Medical Practice - Care Quality Commission

On 6 December 2019 we carried out a full comprehensive inspection of Lees Medical Practice, Athens Way, Lees, Oldham, OL4 3BP.

This was the seventh inspection to the practice since our first inspection on 21 April 2017. It had previously been rated inadequate and placed into special measures. When we inspected the practice in December 2017 and May 2018 the practice made the required improvements, but at the most recent inspection, on 5 December 2018, we found the practice had not sustained the improvements previously made. The practice was rated as requires improvement overall and for each of the key questions. Requirement notices were issued in relation to breaches in Regulation 12 (safe care and treatment), Regulation 16 (receiving and acting on complaints), Regulation 17 (good governance) and Regulation 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This was a full comprehensive inspection. At this inspection we found that improvements had been made under each of the key questions and all the requirement notices had been met.

We have rated this practice as good overall and good for all population groups.

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.

At this inspection we found that:

Safeguarding and infection control procedures had improved to an appropriate level.
Training was being monitored and where the new management team had found gaps training was being sourced.
Complaints were being managed appropriately.
Policies and procedures had been reviewed and were being followed.
There was a new system for safely managing and assessing the needs for home visits and urgent appointment requests.
The significant event process had been improved to an appropriate level.
A new appraisal process was in place.

In addition:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

Monitor all training needs of all clinicians with a view to improving Quality and Outcomes Framework (QOF) results.
Monitor the data being submitted for QOF.
Continue to re-assess the carers’ list so support can be offered to all carers.
Change the CQC registration to reflect the current partnership.

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

We carried out an announced comprehensive inspection at Lees Medical Practice on 5 December 2018.

The practice had been inspected on 21 April 2017. It was rated as inadequate overall and placed in special measures. There were breaches in regulations 11, 12, 17 and 19. Requirement notices were issued for the breaches in regulations 11 and 19, and warning notices issued for the breaches in regulations 12 and 17.

On 3 October 2017 we carried out a focussed follow-up inspection to check that the practice had met the requirements of the warning notices. We found that not all issues had been addressed to a satisfactory standard.

On 20 December 2017 we carried out a comprehensive inspection to assess the progress the practice had made. We rated the practice as good overall, with safe being rated as requires improvement. Requirement notices were issued for breaches in regulations 12 and 19. The practice was taken out of special measures.

On 23 May 2018 we carried out a focussed follow up inspection to check progress had been made in relation to regulations 12 and 19. We found that the required improvements had been made and we rated the practice as good in the safe domain.

This was a full comprehensive inspection carried out on 5 December 2018 made 12 months after the practice was taken out of special measures. This was in accordance with our methodology to check the previous improvements made had been sustained.

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 requires improvement overall.

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

The practice did not carry out all the required checks prior to recruiting new staff.
The infection control lead had not received specific training. A hand wash audit had been carried out by the untrained lead, but GPs had not been part of the audit.
Test results had not been actioned in a timely manner.
Evidence was not held that all staff, including clinicians, had received safeguarding training.
Significant events were not well recorded. There was no clear plan when improvements were required, no timescales, and the person responsible for making changes was not recorded.

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

There was limited monitoring of the outcomes of care and treatment.
There was no system to ensure care plans were regularly updated.
The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
The practice was unable to show evidence of improvement following clinical audits.
The practice manager had not had an annual appraisal.

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

During the inspection we were informed that the practice did not register patients without an address. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this.
During the inspection we were informed that the practice did not know how to respond to changes in patients’ preferred gender, name or title. Following the inspection the practice told us this was incorrect and relevant requests had previously been actioned, but they provided us with no evidence to substantiate this.
Information on the carer’s noticeboard was not up to date.

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

Complaints were not managed in accordance with the policy. They were not used to improve the quality of care.
During the inspection we were informed that there was no protocol for managing home visit requests with GPs having individual preferences. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this.
During the inspection we were informed that there was no protocol for requests for urgent appointments. Following the inspection the practice told us this was incorrect, but they provided us with no evidence to substantiate this

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

The practice had not sustained the improvements made since the previous CQC inspections.
Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a vision, that vision was not supported by a credible strategy.
The overall governance arrangements were ineffective.
Not all policies and procedures were followed.
We saw little evidence of systems and processes for learning, continuous improvement and innovation.

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

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Ensure that any complaint received is investigated and necessary and proportionate action taken in response to any failure identified by the complaint or investigation.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure recruitment procedures are established and operated effectively so only fit and proper persons are employed. Ensure specified information is available regarding each person employed.

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

The areas where the provider should make improvements are:

Review the policy for accepting vulnerable patient onto the practice register.
Have a protocol for home visit and urgent appointment requests.
Participate in social prescribing schemes.
Review information displayed for patients and staff to make sure it is up to date.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection December 2017 – Good)

The key questions are rated as:

Are services safe? – Good

We carried out an announced focused inspection at Lees Medical Practice on 23 May 2018. When we inspected the practice on 20 December 2017 we rated the practice as good overall, and requires improvement in the safe domain. This inspection was to follow up on the breaches of regulation found, and also look at the areas where we identified improvements should be made.

At this inspection we found:

The provider had reviewed their fire risk assessment and ensured all required actions had been completed.
The provider ensured all the required information was available before a new employee started work.
The provider had reviewed its policies to be practice specific.
The provider had reviewed how they organised their electronic document storage. There was a common filing system that all staff could access.
The provider had made the decision to have a Disclosure and Barring Service check for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection April 2017 - Inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Lees Medical Practice on 20 December 2017. The practice was rated inadequate at the inspection in April 2017 and placed into special measures. A focussed inspection was carried out on 3 October to check the progress of the action required, and a rating was not given following that inspection. This inspection (December 2017) was to assess the progress made throughout the practice.

At this inspection we found:

Significant improvements had been made throughout the practice. All staff had been involved in discussions around the improvements required, and new staff had been recruited to help in various aspects of the practice.
Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Since the inspection in April 2017 they had received training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
The practice had improved their process for recognising, recording and investigating significant events. They were discussed in meetings and learning was documented.
Improvements had been made to systems to manage risk. Although further improvement was required in relation to the fire risk assessment there were risk assessments and documented checks in place for legionella, prescription security, equipment and health and safety.
The practice now regularly liaised with the wider multi-disciplinary team to ensure coordinated patient care.
The practice had developed and improved their approach to carrying out clinical audits.
Although the recruitment procedure had improved not all the required information was held for new staff.
Improvements had been made to the way training, including induction training, was managed. The practice manager had devised a training passport so all staff were aware of what training should be completed and what the timescales were.
The practice had improved their complaints process since our previous inspection and we saw they had a process in place to analyse trends at the end of the year.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice had engaged with the Royal College of General Practitioners (RCGP) following the inspection in April 2017 to ensure their improvement plans were robust.

The areas where the provider must make improvements are:

The provider must ensure safe care and treatment is provided.
The provider must ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

The provider should review generic policies so they reflect the needs and processes of the practice.
The provider should review their electronic filing system so documents are well-organised.
The provider should carry out a risk assessment for staff without a Disclosure and Barring Service (DBS) check if they are performing chaperone duties.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 21 April 2017 we carried out a full comprehensive inspection of Lees Medical practice. This resulted in the practice being placed in special measures and Warning Notices being issued against the provider on 14 and 16 June 2017. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe care and treatment and Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Good governance.

On 3 October 2017 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. We found that not all issues had yet been addressed to a satisfactory standard. Although some improvement had been made and some systems had been introduced further improvements were still required to ensure that safety was maintained. In particular we found that :

The practice introduced a new system for recording significant events in May 2017. However we found that there were still some improvements to be made to this system.

The practice now used a local care plan system to identify high risk patients. Care plans had been created for patients living in nursing and residential care and the registered manager told us care plans were also in place for patients with chronic long term conditions and those at risk of unplanned hospital admissions. They told us they would provide further information about these by the end of the week of the inspection, but these were not provided.

The provider carried out some safety checks and risk assessments. These included risk assessments carried out by external professional organisations such as a fire risk assessment, legionella risk assessment and emergency lighting annual check. However we found that there were still some improvements to be made to this system.

The provider had initiated two clinical audits following our previous inspection. Both were in the initial stages of a first cycle.

The provider had introduced a new process of induction for new staff; however we found that there were still some improvements to be made to this system.

The provider had introduced a system to record staff training; however we found that there were still some improvements to be made to this system.

We reviewed the ‘on the day’ urgent appointment system. We were told where cover was required locum GPs were available. We were also told that where children or vulnerable older patients required an appointment these would be accommodated on the day. We reviewed the appointment system for the following day and noted appointments were available.

The rating awarded to the practice following our full comprehensive inspection 21 April 2017 of ‘inadequate’ remains unchanged. The practice will be re-inspected in relation to their rating in the future.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lees Medical Practice on 21 April 2017. Overall the practice is rated as inadequate.

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

Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, health and safety was not a priority, not all required fire safety checks were carried out and not all appropriate recruitment checks had been carried out on staff before employing them.
Incident reporting was not consistent. Some incidents had not been reported and there was no system to review learning points.
Patient outcomes were hard to identify with little or no reference made to audits or quality.
Risks to patients were not always fully assessed and well managed in areas of care planning and hospital admissions.
Not all GPs would see a patient under the age of 16 without a parent being present.
Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
Information about how to complain was available but there was no evidence of learning from complaints.
The website contained out of date information and no-one had responsibility for keeping it up to date.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Patients told us appointments were easy to access.

The areas where the provider must make improvements are:

1. The provider must improve their arrangements for gaining consent:

The provider must ensure all clinicians are aware of their duty to see patients under the age of 16, who have been assessed as being Gillick competent. Gillick competence is used in medical law to decide whether a child under the age of 16 is able to consent to their own medical treatment, without the need for parental permission or knowledge.

2. The provider must ensure safe care and treatment is provided:

The provider must introduce reliable processes for reporting, recording, acting on, monitoring and learning from significant events, incidents and near misses. This includes when patient confidentiality is breached.
The provider must ensure high risk patients are identified and have a care plan in place to monitor their condition and minimise the risk of them being admitted to hospital. Vulnerable patient groups such as those receiving palliative care must be regularly reviewed by the multi-disciplinary team, with evidence of this being kept.
The provider must ensure all relevant safety checks and risk assessments are carried out and updated. These include fire risk assessments and fire safety checks, a legionella risk assessment, checks that equipment and products are within their expiry dates and formal health and safety checks.

3. The provider must improve their governance arrangements:

The provider must ensure a system is in place to monitor the quality of the care and service provided. This includes using clinical audits as a way of identifying improvements that must be made.
The provider must ensure staff are aware of and are following policies that are in place.
The provider must introduce a process to ensure new staff have an induction and training is monitored and recorded.
The provider must review their procedures so that there are enough clinicians to offer emergency appointments each day.

4. The provider must improve their recruitment procedures so there is assurance only fit and proper persons are employed:

The provider must ensure all staff are of good character and that all the required pre-employment checks for new staff have been carried out.
The provider must check the on-going professional registration of clinical staff.

The areas where the provider should make improvement are:

The provider should share complaints with staff and have a system in place to review them and share learning from them.
The provider should review the website so up to date information is included.
The provider should proactively identify carers so appropriate support can be offered.

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

Archived: Lees Medical Practice

All Inspections

6 December 2019

During a routine inspection

5 December 2018

During a routine inspection

23/05/2018

During an inspection looking at part of the service

Professor Steve Field (CBE FRCP FFPH FRCGP)

20/12/2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

3 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

21/04/2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)