Archived: Dr Michael Florin Also known as Norris Road Surgery

Updated 8 October 2015

The GP practice is a single handed practice located on a busy main road in Sale Cheshire. The practice currently has 2318 patients registered. The practice has one part time practice nurse and four part time reception staff.

The practice reception is open 8.00am – 6pm Monday to Friday with appointments available between 9am -11am and 3.30pm – 5.45pm with the GP Monday to Friday and with the nurse Monday and Wednesday she had all day clinics starting at 8.00am with a morning clinic only on Tuesday.

The practice population’s largest group is the 18-65 years age group with its smallest being 85+ age groups. 55% of the practice population have long standing conditions and 39.8% have health related problems in daily life. There are currently 7 patients registered with the practice in nursing homes.

7.5% of the practice population are currently unemployed which is higher than CCG average.

Information published by Public Health England rates the level of deprivation within the practice population group as four on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. However t he areas deprivation score is 18.3, with income deprivation affecting older people higher than both CCG and National average at 20% and income deprivation affecting children at 16.0% within the practice. (Based on 2012 statistics)

Male life expectancy within the area is 80 years, while for females it is 84 years.

The GP does not provide out of hours services to his patients. This is provided by Mastercall. The GP practice delivers care as part of The General Medical Services (GMS) contract which is the contract between general practices and NHS England for delivering primary care services to local communities

The GP had achieved 88.8% out of a potential 100% in 2013/14 in the voluntary completion of the quality and outcomes framework system (QoF), Which is a national performance measurement tool submitted to the local Clinical Commissioning Group. (CCG). National average for this is 94.2%

The GP practice had declared non-compliance when it registered with the Care Quality Commission in April 2013. They were inspected on 28th June 2013 with a specialist advisor and found to be compliant with Regulation 22 only. Compliance actions were issued against Regulations 9,15,16,17,19,20,21,23 Warning Notices were issued against Regulations10,12,13,11,18.of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Following submission of a number of action plans a follow up inspection was carried out on 17th March 2014 with a GP Specialist Advisor. The practice was still found to be non-compliant with Regulation 10 only.

A further visit to the practice on 15th September 2014 found the practice remained in breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. A decision was made to undertake a more in-depth inspection looking at all domains within the new framework of inspection. A further inspection took place in October 2014 under the new framework of inspection. The provider refused to take an active part in the inspection and was found to be overall rated as Inadequate On the basis of this inspection, the ratings given to this practice, and the concerns identified at four previous inspections, this provider was placed into special measures. This was for a period of six months during which time the provider was expected to improve the practice to meet the required regulations and fundamental standards.

Special measures are designed to ensure a timely and co-ordinated response to practices found to be providing inadequate care that gives them support from NHS England and the Clinical Commissioning Group. Practices can choose to get further peer advice and support from the Royal College of General Practitioners. Being placed into special measures represents a decision made by CQC that a practice has to improve within six months to avoid having its registration cancelled.

Updated 8 October 2015

Letter from the Chief Inspector of General Practice

We carried out a follow up inspection on 29th July 2015 at the GP practice of Dr Michael Florin as a result of the practice currently being in special measure due to continued non-compliance with the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found the practice to be inadequate in three of the five domains inspected. However the practice was good at caring for patients but required improvement in the responsive domains. The practice has failed to meet any of the regulatory requirements prescribed after the last inspection in October 2014 and no improvement in meeting the fundamental standards has been made.

Our key findings were as follows:

• The practice had no clear leadership structure, insufficient leadership capacity and no formal governance arrangements in place to support staff to deliver high quality evidence based care to patients accessing the service.
• All areas of the practice were seen to be clean, tidy and well-maintained.
• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment, actions identified to address concerns with infection control practice had not been taken and some staff had not received appropriate training for their role.
• Management of medicines within the practice did not follow practice policy, local or national guidelines for the management of vaccines.
• Appointments with both the GP and nurse were available at short notice, with the waiting time for non-urgent appointments generally around 24 hours. All urgent requests were usually addressed within the day either with a telephone consultation or a face to face appointment offered to the patient.
• We received positive comments from patients who requested to speak with us during the visit.
• There were some policies and guidance in place to support the management of the practice but these had not been shared with staff at the time of the inspection.

Importantly, the provider must:

• The provider must ensure that staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice. They must ensure staff are appropriately trained to take on the roles delegated or expected of them This must include training to allow staff to carry out effective scanning, summarising of patient records and clinical coding.
• The provider must ensure there are systems in place to review and monitor patients who may be at risk or vulnerable within the practice population.
• The provider must take action to address infection prevention and control to ensure that they comply with the ‘Code of Practice for health and social care on the prevention and control of infection and related guidance’. The practice must ensure there is an appropriate policy and staff training in place.
• The provider must take action to ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff.
• The provider must review its systems for assessing and monitoring the quality of the service provision and take steps to ensure risks are managed appropriately.
• The provider must ensure there are formal governance arrangements in place and staff are aware how to implement these to ensure the practice functions in a safe and effective manner.
• The provider must ensure there is a clear strategy for the future of the practice.
• The provider must ensure that all policies and procedures are followed for the safe management and use of medicines which includes ensuring there is an auditable system for reviewing and monitoring the recording of serial numbers on all blank electronic and hand written prescriptions pads held in storage and once allocated to the GP.

This service was placed in special measures in January 2015; this followed five previous CQC inspections where the service was found to be not meeting regulations. Insufficient improvements have been made such that there remains a rating of Inadequate overall for this practice. The domains of Well led, effective and Safe are inadequate and the Responsive domain still requiring improvement. Caring is the only domain which has a rating of Good. As a result of this overall rating of inadequate all population groups remain inadequate. Therefore we are taking action in line with our enforcement procedures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice nurse actively reviewed the care and treatment of people with long-term conditions. The practice nurse monitored the needs of this patient group. Referrals to secondary care were made as soon as the need was identified.

Patients with multiple health conditions had all their health reviews completed on the same visit to minimise the number of visits for the patient. The nurse had developed some protocols to assist in the care of this group of patients.

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Children requiring an appointment with the GP were always given priority and if appointments were not available they were either added to the end of the clinic or offered an appointment with the nurse if she was available to ensure they were always seen promptly. Triage appointments were available with a face to face appointment offered if deemed appropriate. However this triage was carried out by the nurse who had no documented recent training in this role. Referrals to secondary care were made as soon as the need was identified.

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Older people were offered appointments with the nurse at times to suit their ability to access the service. Patients reliant on relatives who worked to escort them to the practice were offered appointments earlier or later in the day although appointment times were limited with the GP between 9 and 5.40pm . Home visits for older people were available on request and flu and shingles vaccines could be administered in the home where needed, Referrals to secondary care were made as soon as the need was identified and all referrals were made by the GP.

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Appointments were only available either earlier or later in the day to assist working patients to access the service with the nurse. The GP surgery times were within working hours of 9am to 5.40pm.

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The nurse informed us it would be the GP who would be responsible for routinely and appropriately referring patients to counselling as well as to mental health services. The GP confirmed this was his role and he was responsible for patients experiencing poor mental health.

Updated 8 October 2015

This provider is rated as inadequate for providing safe, effective and for well-led services. It is also rated as requires improvement for providing  responsive services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Interpreter services were available either planned in advance and an interpreter would attend the appointment with the person or by telephone if the appointment was not pre planned.

The practice could tell us the number of patients with learning disabilities they had within the surgery.

During a review of a sample of patient records we found evidence that information relating a vulnerable person within the practice had not been recorded within the person’s electronic notes. There was no flag on the record to inform staff of the person's vulnerable state. Information relating to this person had not been followed up in a timely manner with other health professionals to ensure the patient received care appropriate to their circumstances.