Archived: Ashwood Surgery Limited

Updated 9 July 2015

Ashwood Surgery Limited is situated in the Weelsby View Health Centre, Ladysmith Road, Grimsby, and South Humberside. The registered patient list size of the practice is 4500. There is one full time female GP and one male locum GP, one full time practice nurse, one full time HCA, a practice manager, a part time secretary and seven part time reception / administration staff. The locum provision in the practice is via a temporary contract.

The practice has personal l medical services (PMS) contract with NHS England to provide essential services to patients who are ill and includes chronic disease management and end of life care.

Patients can book appointments face to face, and by the telephone. The practice treats patients of all ages and provides a range of medical services. The practice has opted out of providing out-of-hours services to their own patients. Patients use the 111 service when the practice is closed.

We undertook a scheduled comprehensive inspection on 21January 2015. During this inspection process we received concerns from people regarding access to care, and the overall management of the service. Because of this and as part of the inspection we also visited the practice unannounced on the evening of 9 March 2015 and during the day on the 10 March 2015.

The practice had previously been inspected in June 2014. This was a responsive inspection to concerns we had received. At the June 2014 inspection we found concerns in relation to care and welfare of people who use services, safeguarding patients, cleanliness and infection control, management of medicines, requirements relating to workers, supporting workers and the management of records. At this inspection we saw that the practice had made some progress to address these concerns.

Updated 9 July 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ashwood Surgery limited on the 21January 2015. As part of this inspection we made a further two unannounced visits to Ashwood Surgery on 9 and 10 March 2015. We gathered information from a variety of sources, spoke with patients, interviewed staff at all levels and checked the right systems and processes were in place.

Concerns regarding this practice from different sources had been raised with us in relation to access to appointments, lack of continuity of care, poor support of locum GPs and that often there was not a GP available to patients. We were told that there was instances when the lead GP was only available in the practice for a short period each day.

Specifically, we rated the practice inadequate for the service being well led, safe, responsive and effective it was rated as requires improvement in caring. It was also inadequate for providing services for the six population groups we reviewed.

We gave the practice an overall rating of ‘inadequate’.

• The practice had previously been inspected in June 2014. During which, we found concerns in relation to care and welfare of patients, safeguarding patients, cleanliness and infection control, management of medicines, requirements relating to workers, supporting workers and the management of records. There were also ongoing financial disputes regarding the payment of bills which resulted in a disruption to service provision. Concerns were also raised around lack or staff support and failure to pay some staff pension contributions. We saw that the practice had made some progress to address these concerns. However, we still found concerns at this inspection relating to assessing and monitoring the quality of service, governance arrangements, ineffective management of risks and monitoring of performance.

• The practice had reviewed and updated the staff handbook and a number of policies and procedures.

• Patients were at risk of harm because systems and processes were not sufficiently robust to keep them safe. For example the practice did not record all significant events in sufficient detail and therefore were unable to learn from these events and prevent reoccurrence.

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. Some safety information was recorded but action and learning from these was not always evident.

• Patients were positive about their interactions with staff and said they were treated with respect and dignity.

• Patients said they found it difficult to make an appointment which included same day urgent appointments. Patients also complained that sometimes there was no GP in the practice. The routine appointment system was not working, and patients were often waiting a long time for non-urgent appointments with the GP of their choice.

• Patients were unhappy about the frequent turnover of staff which led to the lack of clinical continuity of care.

• Lessons learned from significant events were not shared with staff so improvements could be made.

• There was little evidence that national best practice guidelines were being followed.

• We saw instances where patients received care from staff who had not completed appropriate training to deliver it.

• Patients experienced difficulties in accessing urgent appointments.

• The routine appointment system was not working, and patients were often waiting a long time for non-urgent appointments with the GP of their choice.

• There was no evidence of completed audit cycles beyond one audit cycle.

• There was a lack of continuity of care due to the changes in clinical staff. The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider needs to make improvements are;

Importantly, the provider must:

• Ensure there is a system in place for clinicians to be kept up to date with national guidance and guidelines.

• Ensure the practice monitor and review significant events.

• Ensure the practice have systems in place to review the effectiveness of learning from incidents.

• Ensure there are systems for assessing and monitoring risks and the quality of the service provision.

• Ensure audits of practice are undertaken, including completed clinical audit cycles.

• Ensure there are formal governance arrangements to improve patient care. All staff need to be aware of the importance of governance to improve patient care.

• Ensure a sufficient number of clinical staff are employed to safeguard the health, safety and welfare of patients.

• Ensure that patient records contain a rationale for the treatment prescribed and document sufficient information which would enable another clinician to effectively take over care for a patient.

• Ensure appropriate support and training is in place for the practice nurse and health care assistant.

In addition the provider should :

• Ensure the practice website provides up to date information to support patients.

• Ensure there is information to signpost patients to support services or advise on what action to take in an emergency.

• Ensure all staff are familiar and aware of the business continuity plan.

• Ensure there are systems so a locum GPs can access clinical peer support in the surgery.

• Ensure processes are in place to prevent accidental turn off of the vaccination storage fridge which is not hard wired.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 9 July 2015

The provider was rated as inadequate for safe, responsive, effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

There were processes in place and referrals were made for patients whose health deteriorated suddenly. We saw the practice nurse undertook reviews of patients with long term conditions. Longer appointments were available when needed. It was unclear if home visits could be requested for reviews to be undertaken at home. As this is a single handed practice these patients had a named GP. However the practice had for long periods of time operated with only one GP and no nurse; this made it difficult to provide on-going care.

We saw the practice nurse had received appropriate training in the management of long term conditions. The practice provided limited access to information for patients with long term conditions. Information regarding long term conditions was not available on the practice website and there was limited information available in the waiting area to assist patients to self-manage their conditions. The clinical staff had information available in the consulting rooms that could be given to patients at their appointments. We saw 48.6% of the practice population were suffering from a long term condition. We saw from the patient’s records that national guidance in the management of long term conditions was not always being followed.

Updated 9 July 2015

The provider was rated as inadequate for safe, responsive, effective and well led . The concerns which led to these ratings apply to everyone using the practice, including this population group.

Patients had access to a weekly immunisation clinic held by the practice nurse. A full range of immunisations, were offered although data supporting the extent of performance in this area was not made available to us. Midwifery services were held outside of the practice by the community midwives.

We were told there were no formal arrangements were in place for children to access appointments outside of school hours. However staff told us that they would always try and accommodate children. We received several comments from parents who were unhappy with access to same day appointments for their children. We saw on two occasions the practice nurse had reviewed a child and an adolescent offering advice. The health care professional had not been provided with the appropriate clinical training and skills to undertake this role. We saw national guidance and good practice had not always been followed.

The number of patients in the practice under the age of 18 years was well above the national average. Income deprivation affecting children was 31%, well above the national average. However we saw no services to improve access for young children, babies or young people. The problems that may arise from this high number of children in an area of high deprivation were not addressed. We were unable to establish what systems were in place within the practice for identifying and following up children living in disadvantaged circumstances and who may be at risk. For example, children and young people who had a high number of A&E attendances.

Updated 9 July 2015

The provider was rated as inadequate for safe, responsive, effective and well led . The concerns which led to these ratings apply to everyone using the practice, including this population group.

Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered personalised care to meet the needs of the older people and had a range of enhanced services, for example, in dementia and end of life care. The number of older people in the practice was below the national average. As this was a single handed GP practice all patients over the age of 75 years had a named GP. Patients over the age of 75 years identified as needing extra support and had been offered a review at the practice. The medication reviews were undertaken by the GP. The staff we spoke with were proactive in screening for dementia and referring patients for ongoing care and treatment. We did not see evidence that older people were offered rapid access to appointments. Income deprivation affecting older people in this practice was 29% which is above the national average. This suggested this group of patients would require extra support to stay healthy.

Updated 9 July 2015

The provider was rated as inadequate for safe, responsive, effective and well led . The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice offered two days opening from 08.00hrs until 19.30hrs and 08.00hrs to 18.30hrs on the other three days. We saw that appointments during the extended hour’s period on a Thursday were available only with the practice nurse for routine appointments. The locum GP and the practice nurse provided extended cover on a Monday. The single handed GP was available via the telephone for any advice or emergencies on the Thursday. Patients were unable to access online appointments via the website. The practice had planned to develop further access to online appointments and increase the number of patients requesting repeat prescriptions via this route.

We saw health promotion advice was offered but there was limited accessible health promotion material available in the practice. There was no access to up to date information on the practice website. The practice population for those working or in fulltime employment was 55% which is below the national average and 16% were unemployed which is higher than the national average.

Updated 9 July 2015

The provider was rated as Inadequate for safe and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the preceding 12 months was 96% of the total group. The practice referred patients to appropriate support services for those people experiencing poor mental health. We saw evidence the practice worked with local mental health support services situated in the building. Clinical staff were aware of how to care for people with mental health needs and dementia and referred appropriately. We did not see systems in place to follow up on patients who had attended accident and emergency when they had been experiencing poor mental health. We were told there were twenty patients on the dementia register and that the practice was using the dementia toolkit. The dementia toolkit had been launched by NHS England to help GPs make a timely diagnosis and provide appropriate support.

Updated 9 July 2015

The provider was rated as inadequate for safe, responsive, effective and well led . The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice held a register of patients living in vulnerable circumstances including those with a learning disability. There were 40 patients with learning disability registered with the practice. The practice carried out annual health checks for people with a learning disability. At our inspection In January 2015 nine of the 40 patients registered with the practice had accepted the offer of and received an annual health check. The practice offered longer appointments for people with a learning disability. Whilst the practice held a register of patients with a learning disability there was no information about other people who may be vulnerable; such as homeless people or travellers. Systems were in place to raise safeguarding concerns with the local authority safeguarding team and staff had good knowledge of the process.