Archived: Clifton Medical Centre

We carried out an unannounced comprehensive inspection at Clifton Medical Centre and the branch site Victoria Health Centre on 19 December 2019. This inspection was in response to concerns raised about the lack of processes to ensure the safety and care of patients at the practice. We also followed up on a previous comprehensive inspection at the practice in May 2019 where breaches of the Health and Social Care Act 2008 were identified. You can read the report from our last comprehensive inspection on 22 May 2019; by selecting the ‘all reports’ link for Clifton Medical Cenre on our website at:

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 inadequate overall and inadequate for all population groups in the Effective key question, this affects all population groups overall.

We rated the practice as inadequate for providing safe services because:

• The practice were unable to demonstrate they had acted on previous concerns identified . We found no evidence to confirm that formal risk assessments had been completed to ensure risks were managed effectively.
• Following the previous inspection, the practice leadership team could not demonstrate they had reviewed their capacity to consistently deliver high quality sustainable care.
• The practice were unable to demonstrate they had acted on previous breaches identified. We found structures, processes and systems to support good governance remained ineffective. There was no evidence of team meetings being held and we were unable to gain assurances that information was shared appropriately.
• The practice did not have clear systems and processes to keep patients safe. We found safeguarding registers lacked information to advise staff of potential concerns.
• The practice did not have appropriate systems in place for the safe management of medicines. We found non-clinical staff were adding and removing medicines from patients’ records without clinical supervision and oversight.
• Some emergency medicines were available, but these did not cover all the recommended medicines for general practice. No risk assessments had been completed in the absence of emergency medicines to determine the level of risk if required in an emergency situation.
• There were ineffective systems in place for processing information relating to new patients including the summarising of new patient notes. We found over 100 records awaiting summarising from 2017 to 2019.
• We found clinical correspondence had not been actioned, with over 500 clinical letters awaiting action by the GPs.
• Infection prevention and control was not monitored effectively, with no infection control audit in place and no evidence that the clinical lead had completed the relevant training for their role.
• We found prescription stationery was not kept securely, with blank prescriptions left in printers in consulting rooms and the doors were left unlocked when not in use.
• The practice was unable to demonstrate effective management of risks in relation to medicine safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
• The practice was unable to demonstrate how they learnt or made improvements when things went wrong. There was no evidence available of incidents or significant events that had been recorded, reviewed or actioned.

We rated the practice as inadequate for providing effective services because:

• There was limited monitoring of the outcomes of care and treatment. No clinical audits were available to demonstrate quality improvements had been reviewed and actioned.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles. We found limited evidence that staff had received regular reviews and appraisals. There was no evidence to demonstrate that staff were given opportunities for learning and development.
• Some performance data was significantly below local and national averages.
• The practice did not routinely review the effectiveness and appropriateness of care provided. Care and treatment was not always delivered according to evidence- based guidelines. For example, patients on identified as being within a diabetic range had not been followed up appropriately.
• We found patients on the palliative care and learning disability registers had no care plans in place.
• The practice was unable to provide evidence that regular multi-disciplinary team meetings were held to ensure patients received co-ordinated care.

We rated the practice as inadequate for providing responsive services because:

• The practice told us that all complaints were discussed as part of the staff meetings to drive improvement. There was no evidence that complaints had been received and acted on and no minutes of meetings available.
• The practice was unable to demonstrate they liaised regularly with community teams to discuss and manage the needs of patients with complex medical issues.
• The practice was unable to provide evidence that effective care coordination was in place to enable patients with long-term conditions to access appropriate services.
• The practice could not demonstrate that children who had frequent emergency (A&E) attendances were reviewed appropriately.

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

• There was a leadership structure and some staff said they felt supported by management, however effective oversight to ensure governance arrangements were embedded had not been established. For example, risk assessments had not been completed and systems for preventing and controlling the spread of infections was not being carried out.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care. The practice was unable to provide evidence of a vision and credible strategy to ensure quality care was provided. We found, due to the lack of clinical and managerial leadership, the practice had been unable to embed a strategy to improve patient outcomes.
• We identified significant failings in the care of patients, this included: safeguarding concerns not being addressed, overall management of patients with long term conditions and a lack of clinical oversight to ensure patients were receiving adequate care and treatment.
• There were arrangements for planning and monitoring the number of staff needed however, there were no formal plans to reduce the reliance of locums to ensure continuity of care and clinical cover.
• We found limited clinical leadership within the practice and clinical tasks were being completed by administration staff. For example: the review and actioning of clinical letters and the coding of clinical conditions.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

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

• The leadership team told us that the survey results were discussed at practice meetings; however, there was no evidence available to show action plans were in place to address areas where satisfaction was below local and national averages. The practice was unable to provide evidence of minutes of meetings.
• We were told an inhouse survey was carried out to gather patient feedback, however the practice was unable to provide evidence that a survey had been completed.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

• Improve the current process for the recording of carers.

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.

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 unannounced focused inspection at Clifton Medical Centre on 8 January 2020 as part of our inspection programme to confirm that the practice had carried out their plan to meet the legal requirements in relation to urgent notice of decision to impose conditions on the providers registration served on 20 and 23 December 2019 . This report only covers our findings in relation to those requirements.

At the last inspection in December 2019 we rated the practice as inadequate for providing safe, effective, responsive and well-led services. The practice was rated requires improvement for providing caring services. Breaches of legal requirements were found and after our comprehensive inspection we issued urgent notices of decisions to place conditions on the providers registration.

The full comprehensive report on the December 2019 inspection, can be found by selecting the ‘all reports’ link for Clifton Medical Centre on our website at www.cqc.org.uk.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 19 December 2019.

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 found that:

• The practice held appropriate emergency medicines and equipment to respond to medical emergencies. However, systems for managing the stock of medicines available on site were not consistently applied across the main and branch site. The provider had not taken action to ensure inappropriate medicine were not being stored as a medicine to be used in the event of a medical emergency.
• Clinical staff demonstrated the competency to meet patients’ individual needs; however, the provider was unable to show inspectors evidence of the necessary qualifications or demonstrate that they were assessing clinicians’ competencies through clinical supervision.
• There was some evidence of actions being taken for individual patients to ensure appropriate reviews and monitoring were carried out prior to prescribing high-risk medicines. However, the provider had not established an effective system to ensure patients prescribed a high-risk medicine were being monitored appropriately.
• During our inspection, we found the provider had implemented a process to ensure changes to patients’ medicines were only being made by clinicians.
• The provider was unable to provide assurance that Disclosure and Barring Service (DBS) checks had been carried out for identified staff.
• There was limited evidence to demonstrate an effective overarching governance framework to support the delivery of good quality care and changes made by the provider following our December 2019 inspection, had not been communicated effectively within the practice.
• The practice did not have clear systems and processes to keep patients safe and the provider was unable to demonstrate they had acted on previous concerns identified such as the management of safety alerts and infection control. There was no evidence to confirm that environmental risk assessments had been carried out at the main site to ensure risks were managed effectively.
• The practice were unable to demonstrate they had a system in place for sharing learning or to communicate improvements required when things went wrong.

Despite some actions which had been taken to address issues identified at our December 2019 inspection, there was no evidence that actions had had a positive impact on the providers ability to provide a safe, effective and well-led service. Although some actions were ongoing such as areas of medicines management, we found that changes were not communicated effectively throughout the practice which hindered the ability to imbed new systems and processes. As a result, the areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The practice is due to be inspected again within six months of publication of the December 2019 comprehensive inspection report. When we re-inspect, we will also look at whether further progress has been made to enable compliance with Regulation 12: safe care and treatment; and Regulation 17 good governance HSCA (RA) Regulations 2014.

This service will remain 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.

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 Clifton Medical Centre on 26 September 2018. The practice was a new location registered by the provider Dr Devanna Manivasagam on September 2017,and was inspected as part of our inspection programme. The overall rating for the service was requires improvement. Breaches of legal requirements were found and we issued a requirement notice for Regulation 17: Good governance, HSCA (RA) Regulations 2014.

We carried out an announced focused inspection at Clifton Medical Centre on 22 May 2019. The purpose of the inspection was to confirm if the service had made sufficient improvements and met the requirements of the notice.

At the previous inspection we identified areas the provider should make improvements. This included having systems in place to confirm that the defibrillator was in good working order, increasing the uptake for cancer screening, exploring ways to increase the number of carers identified and protecting patient confidentiality during consultations.

During this inspection records we reviewed provided assurance that the defibrillator was in good working order. The practice had increased the number of carers identified and plans were in progress to ensure patient conversations could not be overheard in consulting rooms. The practice had taken action to promote cancer screening. However, at the time of this inspection the uptake for cancer screening remained below the national averages.

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.

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

• Systems and processes were in place to keep people safe.
• There were gaps and inconsistencies in systems of accountability to support good governance and management.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvement are:

• Complete formal risk assessments to ensure potential risks are assessed and managed effectively.

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