All inspections: Hatherleigh Medical Centre

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. (Inadequate in Safe and well led. Good in effective, caring and responsive.)

Hatherleigh Medical Centre had been inspected in April 2016 where it was rated inadequate due to breaches in regulations 12 (safe care) 17 (Good governance) 18 (staffing) and 19 (Recruitment). We then re inspected in December 2016 and placed the practice into special measures for continued breaches of the same regulations. On the following inspection in February 2017 the practice was rated as good (requires improvement in well led). The practice was taken out of special measures.

We carried out an announced comprehensive inspection at Hatherleigh Medical Centre on Wednesday 31 January 2018. The purposed was to follow up breaches of regulations made in February 2017 and following concerns about the leadership at the practice received in January 2018.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

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 – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

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

At this inspection we found:

The practice is a partnership run by the Lead GP and the practice manager / lead nurse practitioner prescriber. For purposes of this report the partners will be referred to as leadership team or partners.
Care and treatment was delivered according to evidence- based guidelines.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide patients with effective care and treatment.
Patients we spoke with said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Patients said they found it easy to make an appointment with a named GP and there was continuity of care now that the locum GPs were more regularly employed.
The practice ran an open surgery daily between 9am and 10.30am and between 4pm and 5pm whereby patients were able to walk in and wait to see a nurse or GP without a pre booked appointment.
The practice held a three monthly diabetic outreach clinic where patients with complex diabetes could be reviewed by the visiting diabetic team from the Royal Devon and Exeter Hospital.
The service offered a ‘Market clinic’ where staff from the practice held an open surgery in the market in Hatherleigh once a year where anybody, including patients not on the practice registered list, could come and have blood pressure, blood glucose and any health queries checked. The practice staff then gave a report to take to the patient’s own practice.

The areas where the provider must make improvements as they are in breach of regulations are to:

Ensure care and treatment is provided in a safe way to patients.

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements include to ensure:

Valid insurance certificates are displayed or available in a timely way
Policies are reviewed to provide current best practice guidance for staff
All staff receive appropriate support, training and appraisal to carry out their duties.
Introduce systems to show that employment records demonstrate continued suitable medical defence cover and current registration with professional bodies whilst staff are employed.
Records for significant events clearly show staff involvement, learning points and actions taken.
Levels of GP and leadership cover continue to be monitored to adequately facilitate safe, effective and well-led services for patients and staff, considering the geography of the locations coupled with the clinical commitments of the partners and recent change in GP cover.
Communication with healthcare professionals is maintained during periods of staff shortages
Systems are in place to ensure any medicines within doctors bags are within expiry date
Invoices used in the dispensary or practice are for the provider rather than previous provider.
Staff have opportunities to attend meetings and are supported to give feedback

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

Letter from the Chief Inspector of General Practice

We carried out this announced comprehensive inspection at Hatherleigh Medical Centre on 20 February 2017. This was following a comprehensive inspection in April 2016 where the overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. We also performed a focussed follow up inspection in December 2016 to look at actions of warning notices made following the April 2016 inspection. The full comprehensive report for April 2016 and focussed follow up inspection in December 2016 can be found by selecting the ‘all reports’ link for Hatherleigh Medical Centre on our website at www.cqc.org.uk .

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 20 February 2017. Overall the practice is now rated as good.

Our key findings were as follows:

There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
Risks to patients were assessed and well managed and the provider had introduced a programme of risk assessments.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
Patients we spoke with and comment cards we received showed patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
The introduction of secure storage of patient’s records and additional space provided for patients who wished to discuss issues privately at the reception area.

Information about services and how to complain was clearer, more readily available and easier to understand. Improvements were made to the quality of care as a result of complaints and concerns.
A weekly review of staffing numbers and skill mix took place across both practices managed by the provider.
There were reported improvements in the culture and leadership. We were informed that more management tasks had been delegated and there was a sense of team developing. Staff said they were aware there were still improvements to be made but morale had improved with the provision of additional new staff.
The provider had changed their website, the poster outside the building and the patient information leaflet to ensure opening times were clear to patients.
The dispensary and medicines were well managed. Additional nursing and dispensary staff had been recruited and some dispensary staff had taken on additional areas of responsibility to relieve pressure from the GP and practice manager.

Patients said they found it easy to make an appointment with a named GP and there was continuity of care now that the locum GPs were more regularly employed.
The practice ran an open surgery between 9am and 10.30am and between 4pm and 5pm whereby patients were able to walk in and wait to see a nurse or GP without a pre booked appointment.
The practice held a three monthly diabetic outreach clinic where patients with complex diabetes could be reviewed by the visiting diabetic team from the Royal Devon and Exeter Hospital.
The service offered a ‘Market clinic’ where staff from the practice held an open surgery in the market in Hatherleigh once a year where anybody, including patients not on the practice registered list, could come and have blood pressure, blood glucose and any health queries checked. The practice staff then gave a report to take to the patient’s own practice.
GPs carried out reviews of their registered patients who were in-patients at two community hospitals.

The practice had good facilities and was well equipped to treat patients and meet their needs.
Staff said there was a clear leadership structure in place and additional staff recruitment meant there was more support available. Staff said they felt more supported by management. The practice proactively sought feedback from staff and patients, which it acted on. A new PPG had been set up.
Improvements to the induction programme and locum pack meant staff were provided with the information needed to perform their roles. For example, the practice had identified mandatory training including safeguarding and infection control training.
The provider was aware of and complied with the requirements of the duty of candour.

However, there were also areas of practice where the provider needs to make improvements.

The Provider should:

Continue to identify and review why exception reporting rates for depression are not within normal ranges.
Review written records to demonstrate the verbal action taken in regard of complaints.
Review audit records consistently to demonstrate learning points and possible improvements are routinely identified to measure change or improvement over time.
Review guidance to ensure security when email consultations take place.
Monitor the outcome of national patient survey results and take appropriate action.

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

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a focussed follow up inspection of a warning notice issued during an inspection of Hatherleigh Medical Centre on 13 December 2016. This wide ranging review was performed to check on the progress of actions taken following an inspection we made in April 2016. We requested an action plan following the inspection in April 2016 which detailed the steps they would take to meet their breach of regulation.

During our latest inspection on 13 December 2016 we found the provider had started to make the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the previous comprehensive report published in August 2016. This can be done by selecting the 'all reports' link for Hatherleigh Medical Centre on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

The practice had started to improve the systems, processes and practices in place to keep people safe. For example there had been:

Improvements made to a new locum pack to ensure it had guidance for reporting welfare concerns of patients
Improvements to the content and organisation of recruitment records
Introduction of a fire risk assessment new fire detection and alarm system.
A review of the control of substances hazardous to health (COSHH) risk assessment.
A weekly review of staffing numbers and skill mix across both practices managed by the provider. However, we noted the provider was not open for all their contracted hours and information about opening times for patients was misleading.
Additional nursing and dispensary staff had been recruited.
Improvements in the way patient’s care and treatment
Review the induction training programme to ensure it included mandatory training including safeguarding and infection control training.
Improvements of systems to ensure all administrative tasks and processes had been followed up or completed including referrals to secondary care.
Introduction of secure storage of patient’s records and additional space provided for patients who wished to discuss issues privately at the reception area.
A new website and patient leaflet introduced; however, some information required updating.
Improvements in information on how to complain including information on the website and providing leaflets and posters.
Improvements to some governance processes. Policies had been reviewed and the number of clinical audits had increased and demonstrated improvements in patient care. New secure systems introduced to back up data.
Medicines were well managed. However, we saw that the GP had prescribed controlled drugs several times for a family member over a period of 4 days in July 2016. This is not recommended by the General Medical Council (GMC).
Reported improvements in the culture and leadership. We were informed that more management tasks were being delegated and there was a sense of team developing. Staff said there were still improvements to be made but morale had improved with the addition of additional new staff.
A new Patient Participation Group set up and had met the week before the inspection to discuss how the group would work.
Communication was better and done both informally and formally through an increased number of meetings.
The providers did not demonstrate they had the capacity to lead effectively over the two GP practice locations they managed.

However, there were also areas of practice where the provider still needed to make improvements.

Importantly, the provider must:

Demonstrate assurances and competence of how the management of the two locations, considering the geography of the locations coupled with the clinical management and leadership commitments of the partners, would provide safe, effective, caring, responsive and well led services.

Introduce and maintain governance systems to monitor and ensure that:

New staff have the qualifications, competence, skills and experience to do so safely.
Information for patients, risk assessments and policies do not contain conflicting information.
Evidence of recruitment has taken place on transfer to more permanent employment at the practice.
Assessment of environmental risk take place to ensure the premises are safe to use.
Processes are in place to ensure prescribing is managed properly.
Sufficient staff are made available to ensure the practice is accessible during contracted hours.
Introduce systems to monitor staff training.

In addition the provider should:

Improve documentation of clinical audit to demonstrate learning points and possible improvements.
Provide evidence to show all staff are competent in dealing with emergencies. and be aware of the Mental Capacity Act 2005.
Complete the staff appraisals programme
Introduce systems to ensure receive the support and guidance they need.
Ensure consistent and accurate information is provided regarding opening times and appointment times.

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 Hatherleigh Medical Centre on 14 April 2016. Overall the practice is rated as inadequate.

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

Risks to patients were assessed but the review and management of risk was compromised by limited managerial time available as the partners covered gaps in clinical staff availability across two locations.
Staff told us the partners were approachable and took the time to listen to all members of staff but that the practice was disorganised.
Staff understood their responsibilities to raise concerns, and to report incidents and near misses. When things went wrong reviews and investigations were thorough. However, lessons learned were not communicated widely enough to support improvement.

The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to by the GPs.
Although there were a number of monthly patient record checks to monitor patient conditions, we saw insufficient evidence that formal audits were driving improvements in patient outcomes.
The practice participated in the admission avoidance enhanced service and reviewed patient cases on regular intervals.
The practice ran an open surgery in the market in Hatherleigh once a year where any person, including patients not on the practice registered list, could come and have blood pressure, glucose and any health queries checked. A report was provided for people to take to their own surgery.
There were Saturday Clinics, 10am to 12pm, as a drop in clinic, with no pre-booked appointments. Email and telephone advice was available.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Results from the national GP patient survey showed that some aspects of patient satisfaction with how they could access care and treatment were at or below local and national averages.
The practice was clean and there were effective systems in place to monitor infection control processes.
Information about how to complain was absent at the practice but available on the website.
Patients told us they did not know how to complain about the practice.

The practice had a number of policies and procedures to govern activity, but some were overdue a review.
Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.

The areas where the provider must make improvements are:

Ensure recruitment arrangements include all necessary employment checks for all staff.
Ensure patients are provided with up to date information about services.
Ensure staff induction training covers all required mandatory training.
Ensure the locum pack for temporary GPs covers all necessary information, including details of local child protection or vulnerable adult contacts or procedures and chaperone guidance.
Ensure patients know how to complain about the practice and maintain full records of all complaints received, following the practice complaint’s policy.
Ensure secure storage of patient paper records and electronic backup tapes.
Ensure an agreed list of what medicines should be within the GP visit bag and maintain a robust system for monitoring the expiry dates of medicines contained within the bag.
Ensure clear patient specific prescription or directions (PSD) for use by Health Care Assistants trained to administer vaccines and medicine.

In addition the provider should:

Address the national patient survey results and develop an improvement plan where results are below local CGG and national averages.
Review the availability of practice policies for staff use to ensure that both electronic and paper polices supplied for staff are the current version.
Review premises risk assessments in relation to the control of substances hazardous to health and fire.
Review patient information leaflets in the patient waiting room to ensure advice reflects current best clinical practice and contact addresses.
Assess the outside facilities, including the patient car park, with regard to the Equality Act.
Review all staff awareness of and additional training needs in relation to the IT emergency panic call system.
Review dispensary standard operating procedures.
Carry out regular patient participation group meetings.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Hatherleigh Medical Centre was inspected on Wednesday 15 April 2015. This was a comprehensive inspection.

Overall the practice is rated as requires improvement.

Specifically, we found the practice requires improvement for providing safe and well led services. It was good for providing a service which was caring, responsive and effective. It is rated as good for providing services to the six population groups.

Hatherleigh Medical Practice provides primary medical services to people living in Hatherleigh and the surrounding areas. This dispensing practice provides services to a primarily older population and is situated in a rural location.

At the time of our inspection there were 2,035 patients registered at the practice. Two GPs were in the process of registering their partnership. One GP held managerial and financial responsibility for running the business. There were three salaried GPs. Four GPs were male and one was female. There was one practice nurse and one health care assistant and one phlebotomist at the practice. In addition there was a practice manager, and additional administrative and reception staff.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

Our key findings were as follows:

A recent change in ownership had caused a lack of clarity amongst staff about the leadership of the practice. Some staff felt unsupported.

Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed.

Risks to patients were assessed and managed.

Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

Information about services and how to complain was available and easy to understand.

Urgent appointments were usually available on the day they were requested.

The practice had a number of policies and procedures to govern activity. The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings.

The practice was clean, had good facilities and was well equipped to treat patients.

Feedback from patients we spoke with and from patient surveys about care and treatment was positive. However, two comments in the last two years on the NHS Choices website were negative.

We observed a patient centred culture. Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this.

Information received about the practice prior to and during the inspection demonstrated the practice performed comparatively with all other practices within the clinical commissioning group (CCG) area.

We found an area of outstanding practise:

In this rural farming area of mid Devon, the practice nurse reached out to a hard to reach group in the local population, the local farmers. This was achieved by regularly organising and staffing a stand in the local weekly village market, offering blood pressure checks and health advice to patients. This service had been provided for over five years. Without this service, local farmers, who cannot easily take time off work sick or visit a GP practice, would find it very difficult to access these positive health promotions. At the most recent market day screenings, 26 patients had been seen. Of these patients, three had elevated blood sugars and three had elevated blood pressure. All patients were given healthy eating and lifestyle advice. Patients who recorded scores of elevated blood sugars or blood pressure were booked an appointment for future monitoring. Patients not registered at the practice who recorded elevated scores were advised to consult their own GP practice for future monitoring.

There was an area of practice where the provider must make improvements:

The practice was undergoing a transfer in ownership from one GP to another GP. As a result the staff expressed a lack of clarity in the leadership of the practice. The provider must ensure visible leadership at the practice on a regular basis in order to support good governance and to monitor risks at the practice.

There were also areas of practise where the provider should make improvements:

The most recent infection control audit had been undertaken in August 2013. The provider should ensure that a comprehensive infection control audit is carried out on an annual basis.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Archived: Hatherleigh Medical Centre

All Inspections

31 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

20 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

13 December 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

14 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

15 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)