Archived: Vicarage Road Medical Centre

Updated 6 March 2018

Vicarage Road Medical Centre is located in a converted end of terrace house in a residential street, with free parking on the surrounding roads and is a part of Waltham Forest Clinical Commissioning Group (CCG).

There are approximately 2500 patients registered at the practice, 8% of patients are over the age of 65 which is lower than the CCG average of 10% and the national average of 17%. Twenty seven percent of patients have a long-standing health condition, which is lower than the CCG average of 47% and the CCG average of 53%. The practice has a higher rate of unemployment than the CCG and national average where the practice has an unemployment average of 13% compared to the CCG average of 7% and a national average of 4%.

The practice has one female salaried partner and a male sessional GP who carry out a total of nine sessions per week. There is a practice nurse who carries out two sessions per week, a practice manager partner and three reception staff members.

The practice operates under a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the most common form of GP contract).

The practice is open Monday to Friday from 9am to 6:30pm except for Tuesdays when the practice closes at 8pm. Phone lines are answered from 9am and the locally agreed out of hours service covers calls made to the practice when the practice is closed. Appointment times are as follows:

• Monday 9:30am to 11:30am and 3:30pm to 5:30pm

• Tuesday 9:30am to 11:30am and 3:30pm to 8:pm

• Wednesday 9:30am to 11:30am and 3:30pm to 5:30pm

• Thursday 9:30am to 11:30am and doors remain open in the afternoon but no appointments are provided)

• Friday 9:30am to 11:30am and 3:30pm to 5:30pm

Vicarage Road Medical Centre operates regulated activities from one location and is registered with the Care Quality Commission to provide maternity and midwifery services, diagnostic and screening procedures and treatment of disease, disorder or injury.

Updated 6 March 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. (Previous inspection March 2017 – Requires improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. As we found three key questions to be inadequate, they applied to all population groups and this means that each population group is also rated as inadequate:

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

This inspection was an announced comprehensive inspection on 23 and 28 November 2017, carried out to confirm that the practice had carried out their plan to meet the legal requirements in relation to breaches in regulation that we identified in our previous inspection on 7 March 2017. There were breaches in medicines management, safe care and treatment, infection control, governance and complaints and significant events processes. The inspection was carried out across two days due to insufficient time made available for us to interview the GP on the first day of this inspection.

At this inspection in November 2017 we found:

• There was no clinical oversight from the GP in the Quality Outcome Framework exception reporting process.

• Childhood immunisation uptake was below national averages.

• On occasions arrangements for alternative clinical cover were not in place.

• Data from the national GP patient survey showed that patients rated services provided by the nurse and access to appointments below the Clinical Commissioning Group (CCG) and national averages.

• The practice did not have up to date personnel records for locum staff members such as assurance of up to date medical defence union cover.

• There were limited policies and processes to govern activity and most policies that were available had not been reviewed in the last 12 months.

• There was minimal management oversight in staff training and completed training such as child safeguarding and infection control was out of date.

• The processes for sharing learning from significant events and complaints with all relevant staff members was not effective.

• The business continuity plan was not sufficient. The previous inspections CQC rating was not displayed.

• Quality improvement was not a priority among the leadership team.

• The practice had clear systems to manage patient safety alerts.

• Three percent of the patients had been identified as carers and there was a carers’ champion who supported them.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• There was an active patient participation group.

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

• 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.

• Ensure the most recent CQC rating is clearly displayed.

The areas where the provider should make improvements are:

• Work to improve the uptake of childhood immunisations.

• Work to improve patient satisfaction with services provided.

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 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• One out of three patients being prescribed the high risk medicine methotrexate had a record of a recent blood test as required by NICE guidelines documented in their record.

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

• Performance for diabetes related indicators was comparable to the CCG and national averages. For example 74% of patients on the diabetes register had a HbA1c blood test result of 64mmol/mol or less in the preceding 12 months compared to the CCG average of 75% and national average of 78%. However there was an exception reporting rate of 27%, which was higher than the CCG average of 17% and the national average of 13%.

• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

• All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• From the sample of documented examples we reviewed we found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.

• Immunisation rates were mostly comparable to the national standard for all standard childhood immunisations.

• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

• The practice provided support for premature babies and their families following discharge from hospital.

  Appointments were available outside of school hours and the premises were suitable for children and babies.

• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics...

• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.

Updated 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

• The practice offered proactive, personalised care to meet the needs of the older patients in its population.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

• Where older patients had complex needs, the practice held multidisciplinary meetings with relevant health and care professionals to deliver a multidisciplinary package of care.

• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

• The practice maintained a carers register and had a carers lead to support carers in the practice.

Updated 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, increasing the number of daily telephone consultations. However patients still reported low satisfaction in the ability to obtain an appointment.

• The practice was a part of the local Hub which provided week day evening and weekend appointments for patients who could not attend the practice during normal working hours.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• Health promotion advice was offered and there was health promotional material available in practice.

Updated 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• The practice maintained a register of patients living with dementia and carried out advance care planning for patients.

• 100% of patients diagnosed with dementia had their care plan reviewed in a face to face meeting in the preceding 12 months compared to the CCG average of 85% and the national average of 84%. Exception reporting was 17% which was higher than the CCG of 6% and the national average of 7%.

• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

• 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive agreed care plan documented in their record in the preceding 12 months compared to the CCG average 91% and the national average of 89%. There was an exception reporting rate of 27%, which was higher than the CCG average of 7% and the national average of 13%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.

• Patients at risk of dementia were identified and offered an assessment.

• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 9 May 2017

The practice is rated as requires improvement for safety, effective, caring, responsive and well led. The issues identified as requires improvement overall affected all patients including this population group.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.