Archived: Brooks Bar Medical Centre

Updated 24 November 2016

Brooks Bar Medical Practice is a purpose built building based in Chorlton Road, Old Trafford and offers services under a General Medical Services contract to 5,800 patients in the Trafford and surrounding areas. The practice lies on the boundary of four areas and the information systems available to the practice do not link with all the secondary care services where patients can be referred.

The level of deprivation within the practice population group is two (on a scale of one to ten with 10 being lowest). The practice also has a higher population of patients under the age of 18 compared to the rest of the CCG as well as high minority ethnicity such as non-English speaking patients.

There were two partners at the practice. One of the partners is responsible for the entire leadership of the practice and all its associated business needs in addition to their clinical duties.

The practice are contracted to supply 19 clinical sessions per week and four administration sessions. One of the partners and a locum GP regularly undertake eight clinical sessions. The other clinical sessions are covered by the lead GP and other locum GPs when they can be secured. There are male and female GPs.

Nursing staff consist of two female practice nurses working part time, a male health care assistant (assistant practitioner in training), 10 administration staff and a practice manager.

The surgery opening times are listed as 8am to 7.30pm on Mondays, Tuesdays, Thursdays and Fridays, closing between 1pm and 2pm for lunch. On Wednesdays the surgery opens at 8.30am until 12.30pm and does not re-open that day. On Saturdays and Sundays the practice is closed. It is also closed between 12.30pm and 3pm each Thursday for protected learning time.

When the practice is closed the patients are directed to the Out of Hours Services. The practice tries not to turn any patients away and sometimes appointments are booked when the reception or surgery is closed. There is an emergency “sit and wait” facility each day and extended morning hours are offered on a Tuesday and Thursday morning with appointments from 7.30am.

We initially carried out an announced comprehensive inspection at Brooks Bar Medical Centre, Old Trafford on 10th November 2015 when the practice was rated inadequate and was placed into special measures. We took enforcement action and issued requirement notices in relation to Regulations 12 (Safe Care and Treatment), 13 (Safeguarding), 18 (Staffing) and 19 (Fit and proper persons employed). At that time we also issued the practice with a warning notice against Regulation 17 (Good Governance) because there was a lack of systems in place to keep the practice safe. We carried out a focused inspection of the practice on 14th June 2016 to check that they had met the terms of the Warning Notice. At that inspection we were satisfied that adequate systems had been introduced to reduce risks. We were satisfied that if these systems were embedded into every day practice and followed consistently then risks would be well managed.

Updated 24 November 2016

Letter from the Chief Inspector of General Practice

We first carried out an announced comprehensive inspection at Brooks Bar Medical Centre, Old Trafford on 10th November 2015 when the practice was rated inadequate overall and was placed into special measures. At that time we also issued the provider with a warning notice because the practice did not have adequate systems to keep patients safe.

We carried out a focused inspection of the practice on 14th June 2016 to review the actions the provider had taken in terms of the Warning Notice. At that inspection there was evidence that systems had been introduced in order to reduce risk but they were not yet embedded. If these systems were embedded into every day practice and followed consistently then users of the service would be kept safe.

Although governance arrangements had improved, many of the key medical staff, who were instrumental in making improvements, had left, or were leaving the practice and this left overall responsibility with one main lead GP. This was in addition to their clinical responsibilities and other lead areas such as safeguarding, significant events, infection control, policies and procedures, human resources, staff meetings and communication.

We carried out a further announced comprehensive re-inspection of Brooks Bar on 30th August 2016 in line with our enforcement policy of services placed into Special Measures. The practice had introduced a number of protocols and business processes to manage the practice. However, we found that these were not embedded well enough and were not consistently followed to sufficiently reduce the risks that had been previously identified.

The practice had been unable to recruit substantive GPs and clinical sessions were predominantly covered by locum staff. We found that safety, effectiveness, care and responsiveness had deteriorated since our last inspection because locum staff were not involved in the governance and administration elements at the practice and communication was ineffective. The practice is therefore still rated as inadequate overall.

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

• Patients were at risk of harm because not all staff fulfilled their responsibilities to raise concerns, and to report and discuss incidents and near misses.

• We found that where risks were identified and escalated to the lead GP they were not dealt with in a timely manner in order to reduce or prevent reoccurrence.

• Patients care plans were in place but they were not patient specific to be able to meet individual needs and preferences. There were repeated prescribing errors, and READ coding inconsistencies. (READ coding is a way of grouping specific conditions so that they can be easily identified and monitored)

• Data showed that some patient outcomes had improved since our last visit. However the practice were still outliers for some of the QOF (or other national) clinical targets and there was no evidence that they were being dealt with.

• The practice had implemented a system of audit and monitoring and had carried out some checks on patients to ensure they were receiving the most appropriate treatment.One audit cycle had been completed.

• Feedback from patients was mixed.Some patients were satisfied with the service they had received.We spoke to seven patients on the day of the inspection.Some were very dissatisfied with the service and identified confidentiality issues.

• There was good information for patients in the waiting room about the different services available to them within and outside the practice. Information was transferrable into different languages.

• The practice had implemented a patient participation group and the group met regularly.

• The practice had a number of policies and procedures to govern activity. These were not yet embedded into every day practice to ensure that they were effective. For example, to ensure that appropriate action was taken when things went wrong.

The areas where the provider must make improvements are:

• Ensure that all events of significance are reported and action is taken to ensure they are not repeated.

• Ensure there is a responsible person, with the required authority, to make sure that action is taken when things go wrong.

• Monitor that all staff receive patient safety alerts and ensure they are actioned.

• Ensure that policies and procedures are embedded and appropriate actions are taken when things go wrong.

• Ensure that all complaints, verbal and written, are dealt with appropriately.

• Ensure that all staff receive training in order to effectively carry out their role.

• Ensure that medicines management is effective.

• Ensure that care planning, system alerts and READ coding on patient records is consistent to identify patients at the end of their life, those receiving palliative care, those who are carers and patients in need of extra support.

• Protect patients’ privacy at all times, specifically in the reception area.

In addition the provider should:

• Review the needs of the practice population and make changes where appropriate.

• Continue to review, update and embed procedures and guidance into day-to-day practice.

• Continue to develop a quality improvement system to include regular full cycle audits and reviews.

• Introduce a system to identify carers and offer them support

This service was placed in special measures in February 2016. Insufficient improvements have been made such that there remains a rating of inadequate for Safe, Effective, Responsive and Well Led. Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 24 November 2016

The provider was rated as inadequate for safe, effective, responsive and well led and requires improvement for caring. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• Nursing staff held lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. There were appropriate systems in place for the call, recall and review of patients with long term conditions.
• The percentage of patients with COPD who had a review undertaken, including an assessment of breathlessness in the preceding 12 months was 91% which was higher than the local and national averages of 89%.
• Indicators for all diabetes interventions were lower than average (full detail in the main body of the report) with high exception reporting. Exception reporting is where a practice does not include a patient in the overall data submission for specific reasons.
• Longer appointments and home visits were available when needed but there was evidence that home visits were not regular occurrences.

Updated 24 November 2016

The provider was rated as inadequate for safe, effective, responsive and well led and requires improvement for caring. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• There were systems in place 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 A&E attendances. Immunisation rates were lower than average for standard childhood immunisations.
• Staff told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• Although data showed that cervical screening rates were lower than average, they had improved.
• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 24 November 2016

The provider was rated as inadequate for safe, effective, responsive and well led and requires improvement for caring. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• Care and treatment of older people did not always reflect current evidence-based practice, and some older people did not have care plans where necessary. 
• Over 75 health checks had recently been implemented and were being carried out by the Health Care Assistant.

Updated 24 November 2016

The provider was rated as inadequate for safe, effective, responsive and well led and requires improvement for caring. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• Appointments were available from 7.30 am on two mornings a week and until 7.30pm on three evenings a week.
• There were daily “sit and wait” appointments but these were not suitable for patients who were working because of waiting times of up to an hour or more.
• Prescriptions could be requested by email.
• There was no practice website and it was not easy to book appointments on-line

Updated 24 November 2016

The provider was rated as inadequate for safe, effective and well led and requires improvement for caring and responsive. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 48% which was lower than the local and national averages of 85% and 88% respectively.
• Data showed that 87% of patients with dementia had received a face to face review in the previous twelve months but there was no evidence that the practice carried out advanced care planning for patients with dementia.

Updated 24 November 2016

The provider was rated as inadequate for safe, effective and well led and requires improvement for caring and responsive. The issues identified as inadequate and requiring improvement overall affected all patients including this population group. We also found:

• The practice held a register of patients living in vulnerable circumstances such as children on the “at risk” register.
• The practice offered longer appointments for patients if they needed one.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff 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. There were no recent safeguarding incidents.