Archived: St Marys Medical Centre

Updated 14 April 2016

St Marys Medical Centre is situated in a largely residential area in the north west of Nottingham. The centre was purpose-built just over 30 years ago.

The family run practice is a partnership between two GPs (one male and one female). One of the GPs, who is also the Registered Manager for St Marys Medical Centre, works at another local GP practice, where they are also a GP partner. This GP does see patients at St Marys if they specifically request to see him, or if the patient expresses a preference to see a male GP. However, this GP did not provide any dedicated sessions at the practice.

St Marys Medical Centre does not employ a practice manager or a practice nurse and has only three employees, all of whom are part-time reception staff.

The registered practice population of 1,100 are predominantly of white British background, and are ranked in the most deprived decile meaning this is an area of high deprivation. This can be an indication of high demand for health services. The list size is showing a trend towards a gradual decrease in numbers. The practice age profile is broadly in line with national averages for 25-64 year olds, but has slightly lower percentages of patients aged under 24 and over 65.

The practice opens from 8.30am until 3.30pm, and then from 4.30pm until 6.30pm Monday to Friday, apart from on a Thursday afternoon when the practice closes at 12.30pm. GP appointments times are available each morning from 9.30am through to 11am, and from 5pm to 6pm in the afternoon apart from Thursday. An extended hours GP surgery is provided from 6.30pm until approximately 7.20pm on a Wednesday evening to accommodate patients with work commitments.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to Nottingham Emergency Medical Services (NEMS) via the 111 service.

The practice holds a General Medical Services (GMS) contract to provide GP services which is commissioned by NHS England.

Updated 14 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Marys Medical Centre on 10 February 2016. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective, caring and well-led services. Improvements were also required for providing responsive services. The concerns which led to these ratings apply across all the population groups we inspected.

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

• Patients were at risk of harm because the systems and processes in place did not always ensure the safety of patients. For example, patient records were not always updated following consultations, and some follow-up tasks had not been actioned by the GP.

• The practice team were unclear regarding their responsibilities to report incidents and near misses, and there was no evidence of learning by sharing findings with staff. Reviews and investigations were not thorough enough to identify key issues.

• The provider did not have robust processes to support child and adult safeguarding. Documentation was inaccurate, and there was no liaison with other professionals in relation to those individuals considered to be at risk. Policies were out of date and lacked clarity. The practice had not identified any vulnerable adults on their patient list.

• We saw limited evidence that audits were driving improvement in performance to improve patient outcomes.

• The practice could not provide evidence that they had completed actions identified by an external infection control audit undertaken in March 2015. Staff had not been offered immunisations to prevent the risk of cross-infection. Therefore, there was a potential safety risk to patients and staff on site.

• Nationally reported data showed that most of the patient outcomes were comparable with local and national averages.

• Patients told us that it was easy to get an appointment to see a GP. Patients told us they felt they were cared for well, and were positive about their interactions with staff. They told us that they were treated with compassion and dignity.

• The provider had insufficient leadership capacity and did not employ a practice manager. Most of the duties were covered by one of the GP partners who was primarily based at a different location.

• The overarching governance framework did not operate effectively, nor support the delivery of good quality care. For example many policies and procedures were overdue a review and some were absent. Employed staff had not received an annual appraisal.

• There were insufficient staffing levels to ensure safety and provide effective service delivery. There was usually only one GP and one receptionist on site. The practice did not employ nursing staff.

• Information about services and how to make a complaint was available in the waiting area, although the complaints information did not provide sufficient detail for patients.

• The practice did not have an active Patient Participation Group (PPG) and therefore patients did not have a robust mechanism to ensure the voice of patients was heard.

• Staff files were not organised efficiently. Details of pre-recruitment checks were largely absent and training details were not recorded and updated centrally.

The areas where the provider must make improvements are:

• Implement robust and effective systems for identifying and managing child and adult safeguarding concerns.

• Ensure patients receive safe care and treatment and risks are mitigated by; introducing robust processes for reporting, recording, investigating, acting on and monitoring significant events, incidents and near misses; carrying out completed clinical audits to improve patient outcomes; taking action to address the identified concerns with infection prevention and control practice; ensuring systems for checking medicines within the practice are strengthened and ensuring patient records are contemporaneous and accurate .

• Ensure effective systems are in place to enable the provider to seek and act on feedback in order to constantly evaluate the services by ensuring that people affected when things go wrong receive reasonable support, and an apology where necessary.

• Ensure effective systems are in place to enable the provider to identify, assess and mitigate risk for example by ensuring recruitment arrangements are robust, records can be found and accessed easily and staff files contain evidence of all necessary pre-employment checks for all staff.

• Ensure effective systems are in place to enable the provider to assess and monitor the quality of service by providing staff with up to date and appropriate policies and guidance to carry out their roles in a safe and effective manner, which reflect the requirements of the practice and local and national guidance, implementing formal governance arrangements, ensuring there is leadership capacity to deliver all improvements; ensuring there is sufficient clinical capacity to provide cover for GPs and ensuring effective systems are in place to record staff training and staff appraisals.

In addition the provider should:

• Ensure risk assessments are considered when risks have been identified. For example, lone working arrangements and the absence of a defibrillator on site.

Further to the inspection, we have taken urgent suspension enforcement action for a period of three months under Section 31 of the Health and Social Care Act 2008, which is subject to a right of appeal. Further to the inspection, we have taken urgent suspension enforcement action for a period of three months under Section 31 of the Health and Social Care Act 2008, which is subject to a right of appeal. An appeal was lodged by the provider which has been heard and dismissed by the First-tier Tribunal.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains 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 practice 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.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 14 April 2016

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

• A review of patients’ notes raised concerns in respect of the use of clinical coding, the full details of the consultation being recorded, and the regularity of reviews. There was an incomplete record of the patient’s health and medical history.

• Reviews of patients’ long-term conditions were offered with the GP as part of the standard appointment system. There were no dedicated long-term condition clinics and no nurses employed at the practice to undertake these.

• Audit was not being utilised effectively to check and improve on outcomes for patients with long term conditions and to ensure treatment was being delivered in line with best practice guidelines.

• The practice had achieved 93.9% for clinical indicators in the Quality and Outcomes Framework in 2014-15. This compared to 91.8% locally within the CCG and 95.1% nationally.

• Longer appointments and home visits were available when needed. However, not all patients had a personalised care plan or structured annual review to check that their health and care needs were being met.

• The diabetic nurse specialist visited the practice to see patients on a monthly basis to provide insulin initiation and management.

• The practice referred patients with diabetes to a structured education programme called Juggle. Informal feedback from patients about the service was positive.

Updated 14 April 2016

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

• The practice did not have a robust process or systems in place to ensure the safe care of vulnerable children.

• There were no regular meetings to identify and follow up children and young people in this group who were living in disadvantaged circumstances and who were at risk of harm or abuse.

• The site was not conducive to the needs of mothers and children. There were no dedicated baby changing or breast feeding facilities

• Well-women services including contraceptive advice, pre-pregnancy care, and guidance on self-examination for breast screening were available

• Weekly baby clinics were offered for child health surveillance and immunisations

• Immunisation rates for the standard childhood immunisations were mixed. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from  81.1% to 100% (CCG  rates ranged from 91.1% to 96.3%) and five year olds from 78.9% to 100% (CCG rates ranged 86.9% to 95.4%). Alerts showed on the computer screen to highlight when immunisations had not been administered to prompt the GP to encourage this, or to do these opportunistically when the patient attended with another problem.

• Sexual health advice and chlamydia screening were offered at the practice.

Updated 14 April 2016

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

• Care and treatment of older people did not always reflect current evidence-based practice, and older people did not always have care plans where necessary.

• The leadership of the practice had not fully considered the needs of older people and were therefore not attempting to improve the service for them. Services for older people were reactive, with limited evidence of engagement with this patient group to improve their experience.

• The percentage of people aged 65 or over who received a seasonal flu vaccination was 69.1% which was slightly below the national average of 73.2%

• Longer appointments and home visits were available for older people when needed.

• The practice was part of a cluster arrangement with other local practices, and the cluster had access to a housebound scheme in which nurses visited older people at home to undertake health checks and vaccinations. The practice had made five referrals to this scheme in the last 12 months, but could not provide us with any data on outcomes to demonstrate the impact of this service for their patients.

• Older patients could be referred to befriending groups for support where indicated. The practice informed us that this would usually be arranged via the care co-ordinator and not by them directly.

Updated 14 April 2016

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

• The needs of the working age population, those recently retired and students had been considered and the practice had adjusted the services it offered to some extent to make them more accessible and flexible.

• The practice offered online services including booking appointments and ordering repeat medications. However, the website was difficult to navigate in order to facilitate this.

• The practice had not implemented electronic prescribing whereby the patient’s prescription would be directed to the pharmacy of their choice.

• Health promotion advice was offered and there was health promotion material available at the practice. The practice staff were unable to provide information on the number of health checks that had been undertaken.

• The practice’s uptake for the cervical screening programme was 75.7%, which was below the CCG average of 81.5% and the national average of 81.8%.

Updated 14 April 2016

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

• The practice had achieved 84.6% for mental health indicators within QOF. This was lower than the CCG average of 88.7% and the national average of 92.8%

• Information provided by the practice indicated that 72.7% of patients with poor mental health had a documented care plan in place in the year to date. However, we reviewed the records of two patients coded as having a care plan and we observed that the information was insufficient to be considered as an effective care plan.

• The practice did not have a register of patients with dementia. The practice informed us they intended to encourage patients and their relatives to seek support if there was a potential diagnosis of dementia.

• The practice had not established links with community mental health teams in the case management of people experiencing poor mental health, including those with dementia.

• The practice had told patients experiencing poor mental health about how to access support services including self-referral to talking therapies. Literature was available in the waiting area to support this.

Updated 14 April 2016

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

• The practice held a register of patients with a learning disability. The practice did not meet with other professionals to plan or review care, but the GP informed us they knew the patient and their families very well and that no additional support was required

• The practice had not worked with multi-disciplinary teams in the case management of vulnerable people, other than those identified through the enhanced service to keep people at risk of hospital admission in their own homes.

• It had told vulnerable patients about how to access various support groups and voluntary organisations.

• Staff had some knowledge in how to recognise signs of abuse in vulnerable adults and children, and were aware of their responsibilities regarding contact relevant agencies with concerns.

• There was a lack of awareness in identifying those patients who required support. For example, patients were not deemed to be vulnerable if they had contact with relatives, and the practice did not have a carers register in place.