The Care Quality Commission
  • Doctor
  • GP practice

Archived: Eastmoor Health Centre

Overall: Requires improvement read more about inspection ratings

Windhill Road, Eastmoor, Wakefield, West Yorkshire, WF1 4SD (01924) 201614

Provided and run by:
Dr Emmanuel Ashaley Okine

All Inspections

17 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. At a previous inspection carried out on 12 and 20 April 2017 the practice was rated as Inadequate overall. A focused inspection carried out on 5 October 2017 did not assess ratings for the practice and was used to assess compliance against Warning Notices, which had previously been served on the practice in light of identified breaches of regulation. At that inspection, we found the provider had made the improvements required.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

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

We carried out an announced comprehensive inspection at Eastmoor Health Centre on 17 January 2018. This was to check that the practice had taken sufficient action to address a number of significant shortfalls we had identified during our previous inspection of the practice on 12 and 20 April 2017. Following this inspection, the practice was rated as inadequate for providing safe, effective and well-led services; and requires improvement for providing caring and responsive services. Overall it was rated as inadequate. We also issued two warning notices and a requirement notice for breaches of regulations under the Health and Social Care Act 2008 and placed the practice into special measures. A subsequent focused inspection carried out on 5 October 2017 found that the two warning notices had been complied with. The requirement notice was considered complied with at this inspection.

At the time of this inspection the practice was in a transition period as the current provider was in the process of retiring from the practice. They were working closely with a potential new provider to ensure continuity of service for patients and staff at Eastmoor Health Centre.

At this inspection we found:

  • The practice had made some improvements since the last comprehensive inspection in April 2017. We saw that remedial actions which included those in relation to the management of patient safety and medicines alerts, infection prevention and control and quality improvement activity had been actioned and sustained.

  • However we saw that the significant event process was being applied inconsistently and that the management of medicines still required improvement. These were areas of work which had previously been highlighted to the practice and had improved at the focused inspection in October 2017.

  • The practice had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.

  • Team meetings had not taken place for a period of three months and annual appraisals for six members of staff had not been completed.

  • The practice had a comprehensive, pre-planned programme of quality improvement activity.

  • The practice was generally below local and national averages for its satisfaction scores on consultations with GPs and nurses.

  • Some staff personnel records were incomplete and lacked detail with regard to induction received, checks on identity and verifying the full immunity status of staff.

  • The practice had recently formed a patient reference group and had developed relationships with local community and health groups, and were using these to improve patient engagement in areas such as bowel and breast cancer screening.

  • Whilst leadership and oversight within the practice had shown some improvement, we saw that this had not been fully sustained in all areas.

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.

  • Review and improve the level and detail of information contained in staff personnel files to include information with regard to induction received, identity checks carried out and staff immunity status.

The areas where the provider should make improvements are:

  • Review and consider how best to improve satisfaction scores from the national GP patient survey.

  • Review staff capabilities to run checks on patients in receipt of high risk medication.

  • Review procedures with regard to cleaning schedules and the accuracy of cleaning records.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service. These improvements now need to be sustained moving forwards, and improvements made in some other areas.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced, comprehensive inspection of Eastmoor Health Centre on 12 April 2017 and 20 April 2017. We identified three breaches of regulations and issued warning notices for two of the breaches. This focused inspection carried out on 5 October 2017 was to check whether the provider had taken steps to comply with the legal requirements for these two breaches. The two breaches of regulation we inspected against were for:

  • Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment.

  • Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good governance.

This report only covers our findings in relation to these requirements. You can read the report from the last inspection carried out on 12 and 20 April 2017 by selecting the reports link for Eastmoor Health Centre on our website at www.cqc.org.uk

Our key findings were as follows:

  • Improvements had been made with respect to patient safety following our last inspection on 12 and 20 April 2017. For example:

    • New processes had been put in place to report and manage significant events and safeguarding concerns.

    • Patient safety and medicines alerts were being received, assessed and when necessary, actioned appropriately.

    • Patients being treated with high risk medications were being effectively monitored.

    • Care planning for patients with long term conditions, and emergency care planning for vulnerable patients was effectively embedded.

    • The practice was working with a number of specialist cancer awareness groups and community groups to improve patient participation in national breast and bowel screening programmes.

  • Improvements had been made with regard to effective governance and management within the practice. For example:

    • A programme of clinical audits had been established and carried out. These audits were used to assess and improve clinical practice. The audits were focused on areas which had been identified as needing to improve during the previous inspections.

    • Measures had been put in place to ensure that staff who carried out cytology screening (cervical smears) and travel vaccinations were appropriately trained, and that the quality of this work was assessed to ensure that it was being carried out in accordance with national guidance. .

    • Clinical meetings were being held on a weekly basis. In addition practice meetings had been established; however this initial improvement had not been sustained as recently practice staff meetings had not been held on a regular basis.

However, there were still some areas of practice where the provider should make and maintain improvements.

The provider should:

  • Improve the level and detail of information contained in staff personnel files, to include information with regard to identity checks and staff immunity status.

  • Complete the process of reviewing and updating lapsed and out of date policies and procedures, ensuing they are readily accessible to staff.

  • Review the areas of low patient satisfaction contained in the national GP patient survey and take steps to improve in these areas.

  • Review the frequency of practice staff meetings being held.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 April 2017 and 20 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a focussed inspection of the provider on 12 April 2017. This was to follow up areas of non-compliance identified at an earlier comprehensive inspection carried out in August 2016. As a result of this earlier inspection the practice had been rated as Requires Improvement overall with individual domain ratings of:

  • Safe – Requires Improvement

  • Effective – Requires Improvement

  • Caring – Good

  • Responsive – Good

  • Well-led – Requires Improvement

During the course of the focussed inspection we identified a number of new concerns. As a result of these, we returned to complete a comprehensive inspection of the practice on 20 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, the practice had not monitored and actioned all medicine and patient safety alerts.

  • Concerns regarding quality, effectiveness and competency had led to the suspension of the cytology and travel vaccination services within the practice.

  • The reporting and actioning of significant events and safeguarding concerns was inconsistent and there was no evidence of learning and communication with staff regarding these occurrences. In addition, meetings to discuss safeguarding concerns were not held on a formal basis and relied on ad hoc meetings where minutes were not kept. We were told when incidents occurred the practice was open in its approach and informed and apologised to patients.

  • Little or no reference was made to audits or quality improvement activity within the practice, and there was no evidence that the practice was comparing its performance to others; either locally or nationally. For example, clinical audit activity was limited and did not address key issues of performance and improvement.

  • We observed patients being treated with compassion and respect. However the practice had only limited engagement with patients. For example, there was no patient participation group in operation within the practice. In many areas the national GP patient survey showed that the practice was rated by patients below local and national averages.

  • The practice had limited formal governance arrangements. Staff meetings were held infrequently, staff appraisals had not been rolled out to all staff and there was evidence of limited oversight, monitoring and supervision of staff in some specialist areas of work.

  • There was no active tracking of policies and procedures to ensure that these were kept up to date. For example, the infection prevention and control protocol had been due for review in January 2017 however; a review had not been carried out. In addition all staff did not have access to the practice intranet where key policies and procedures were stored.

  • Some staff personnel records were incomplete and lacked detail with regard to identity checks and verifying the full immunity status of staff.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There had been only limited progress made with regard to areas identified as requiring improvement during the inspection carried out in August 2016.

The areas where the provider must make improvements are:

  • The provider must provide care and treatment in a safe way by assessing, monitoring, managing and mitigating risks to the health and safety of service users. This includes making improvements to the incident reporting processes, infection prevention and control practices, participation in national screening programmes such as those in relation to breast and bowel cancer, and the proper and safe management of medicines; including the monitoring and actioning of safety alerts.
  • The provider must establish systems and processes and operate these effectively to ensure good governance. This includes implementing systems for assessing and monitoring risks and the quality of services provided, and improving communication and information sharing across the practice.
  • The provider must ensure that persons employed receive appropriate support, training, supervision, monitoring and appraisal to enable them to carry out the duties they are employed to perform.

The areas where the provider should make improvement are:

  • The practice should review its operating procedure which allowed patient family members to act as interpreters and ensure safeguarding processes around this practice are effective.

  • The practice should continue to review their engagement with patients and the results of patient satisfaction surveys to ensure that it can meet the needs of the patient population in the future and improve outcomes.

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

16 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eastmoor Health Centre on 16 August 2016. Overall the practice is rated as requires improvement.

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

  • The practice had developed systems and processes to raise concerns, and to report incidents and near misses. However, during the inspection it was apparent that the reporting of incidents was inconsistent and therefore learning opportunities could be missed.

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented to an acceptable standard to ensure patients were kept safe. For example, the practice procedures for monitoring and acting on medicines alerts had lapsed, and issues were identified in respect to infection prevention and control.

  • 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.
  • Data showed patient outcomes were low compared to the national average.
  • Patients told us they were treated with compassion, dignity and respect.
  • Information about services and how to complain was available and easy to understand.
  • Staff experienced difficulty in accessing information from the practice IT system in relation to policies and personnel records.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services was available, and staff could access translation and interpretation support when required to support patients with specific needs.
  • The provider was aware of and complied with the requirements of the duty of candour.

There were areas where the provider must make improvement:

  • The practice must re-instate the system for receiveing and acting upon medicines alerts and take steps to ensure that all significant events are recorded, investigated, analysed and learnt from when appropriate.

  • The practice must ensure there are effective systems in place to assess, monitor and improve the quality and safety of services provided. Quality improvement activity was limited and the systems in place to keep patients and staff safe were not always effective.

In addition the provider should ensure:

  • Infection prevention and control within the practice should be improved. The included work in relation to the storage of sharps and the replacement of curtains in clinical rooms.

  • The level of information contained in recruitment and personnel files required improvement. In particular information in relation to staff identity and the immunity status of staff was missing from three files during the inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice