Archived: Brooks Bar Medical Centre

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

Letter from the Chief Inspector of General Practice

On 10th November 2015 we carried out a full comprehensive inspection of Brooks Bar Medical Surgery which resulted in a Warning Notice being served against the provider. The Notice advised the provider that the practice were failing to meet the required standards relating to Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance. The parts of the regulation that the practice were failing to meet specifically related to the systems that the provider had in place which were not established and operated effectively to ensure compliance with the requirements. In particular they did not :

• Assess, monitor and improve quality and safety

• Assess, monitor and mitigate risks relating to the health, safety and welfare of patients and staff

• Seek and act on feedback from relevant persons and other persons on the services, including patients and staff

• Monitor, evaluate and improve their practice through any feedback received.

On 14th June 2016 we undertook a focused inspection to check if the practice had achieved compliance with the Warning Notice which we issued on 11th December 2015. At this inspection we found that the provider had satisfied the requirements of the Notice.

Specifically we found that :

• There had been a number of staff changes and key members of the medical and administration team had either left or were due to leave the practice. Whilst progress had been made regarding governance improvements,the remaining and any new partners must ensure that an adequate focus is maintained to secure and embed these and other improvements required.

• The practice were currently trying to recruit medical and reception staff. The onus was on existing and locum staff to support the practice in the meantime and absorb the daily clinical and administration tasks.

• There were systems in place to assess and monitor risks at the practice and steps had been taken to mitigate those risks, in relation for example, to health and safety and recruitment.

• The practice had introduced systems to monitor that clinical and non-clinical audits were being carried out and discussed. This would be further improved when the practice could evidence over time that actions identified were carried out and outcomes were reviewed to quantify their impact.

• A process to report, record, discuss and review significant events had been embedded. This would be further improved when the practice could evidence over time that trends were monitored, learning was achieved and actions identified were carried out and monitored.

• There were systems in place to identify and manage vulnerable patients and to monitor clinical risks such as medicine alerts, recalls and clinical coding.

• Governance arrangements were improving but there was a lot of onus on only one GP who, in addition to their clinical responsibilities, was also the lead for all tasks such as safeguarding, significant events, infection control, policies and procedures, human resources, staff meetings and communication.

• Staff told us that communication had improved and they felt more valued and empowered to effect change.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice