Contents
- Foreword from the Chief Inspector
- Overview of inspections in Year 5
- Key findings from inspections in Year 5
- Conclusion
Foreword from the Chief Inspector
I am pleased to present our annual report of the quality of care in Defence Medical Services (DMS) for 2021/22. This report sets out the findings from inspections in Year 5 of this programme.
Armed forces personnel and their families deserve high-quality, accessible care as much as the rest of society. The Defence Medical Services Regulator (DMSR) has therefore continued to commission CQC to inspect healthcare and medical operational capabilities, which started with a programme of inspections in 2017/18.
Our inspections aim to highlight both notable practice and problems that we find, and to make sure that military health services address issues for the benefit of both patients and the staff working in them. Where we found concerns in the first years of the programme, we have carried out follow-up visits to ensure that the necessary improvements have been delivered. We have found that almost all services have made improvements.
In rare cases, where we found poor and unsafe practice that put patients at risk, we escalated our concerns to DMSR who took regulatory action, with Defence Primary Healthcare providing urgent support to these services to improve.
In our inspection reports, we continue to highlight exemplary practice to encourage other services to learn from it and to adapt what is relevant to use in their own improvement journey. We have identified characteristics at the heart of high-quality military healthcare services:
- failsafe systems to underpin safe and effective care, and comprehensive training so that staff know how to use them
- proactive relationships with key stakeholders, such as welfare teams, local NHS services, safeguarding teams, rehabilitation services, and mental health services
- flexible use of regional staffing resource to ensure that priority areas are always adequately staffed
- assessment of health needs to identify and meet the operational needs of the Force as well as the health and wellbeing needs of patients and their dependants
- shared learning across practice teams and the wider health and military communities
- multi-disciplinary teams that work together seamlessly to place the patient at the centre of the care pathway
- strong, inclusive leadership teams that communicate consistently and encourage improvement and innovation across military, civilian, and regimental staff groups.
Any poor care that we identified in Year 5 was mainly on our inspections of medical centres – including some that we inspected for the first time and some that we were re-inspecting. Encouragingly, most medical centres re-inspected in Year 5 demonstrated sufficient positive improvement to confirm that the quality of care had improved. The quality of care provided in regional rehabilitation units and departments of defence community mental health facilities inspected in Year 5 was generally good.
In Year 5, we also carried out DMSR-led assessments of two overseas medical facilities using an entirely virtual methodology. However, we did not apply ratings or publish reports as these were pilot inspections to develop future methods.
I am pleased that DMSR continues to recognise the value of CQC’s inspections and the resulting improvements to care. I would also like to commend military and civilian personnel for their hard work and commitment to delivering high-quality, safe and effective care.
The Defence Medical Services Regulator and CQC continue to be committed to ensuring that armed forces personnel and their families have access to the same high-quality care as the rest of society.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Overview of inspections in Year 5
In 2021/22, we carried out 31 first comprehensive inspections and published reports for:
- 14 medical centres (including primary care rehabilitation facilities (PCRFs) where DMS were able to provide specialist advisors with the expertise of physiotherapy and exercise rehabilitation)
- 12 dental centres
- 2 regional rehabilitation units (RRUs)
- 3 military departments of community mental health (DCMHs).
We also piloted two overseas assessments that were led by DMSR using an entirely virtual methodology. This involved assessing the care delivered at both Brunei and Kenya medical centres by interviewing staff using a communication platform with videoconferencing facilities and reviewing documentation and photographs. As these two assessments were pilots, we did not give ratings or publish reports.
At the request of DMSR, we created methods to inspect urgent care and pre-hospital emergency care (PHEC) services within the military setting. We planned two pilot inspections, but in both cases when on site to start the work it became clear that the care provided was not sufficiently extensive to merit a bespoke inspection. The pilots were therefore halted and a PHEC pilot inspection will go ahead in Cyprus in Year 6.
In this fifth year, we also carried out 23 follow-up inspections to ensure that services have resolved the concerns found on initial inspections. We re-inspected:
- 17 medical centres (including primary care rehabilitation facilities where DMS were able to provide the expertise of physiotherapy and exercise rehabilitation specialist advisors)
- 1 dental centre
- 2 regional rehabilitation units
- 3 military departments of community mental health
See all inspection reports for DMS medical facilities.
Key findings from inspections in Year 5
Medical centres
All military personnel, some dependants and some civilian staff are entitled to use the services of a military GP practice. Unlike most NHS patients, military staff do not have the right to register with a GP practice of their choice but must register at the location where they are assigned.
The focus of our approach continues to be the quality and safety of services, based on the things that matter to people. This enables us to get to the heart of people’s experiences.
In 2021/22, the DMSR identified which medical facilities should be inspected, and asked CQC to inspect some services where there was a known risk as well as those with no known risks. DMSR also requested that we assess two overseas medical centres adopting a virtual pilot approach, which we did not rate.
Military general practice and NHS general practice are different in several ways, for example:
- DMS practice populations are much smaller than in NHS practices
- providing services for families is far less common
- there is a greater focus on delivering occupational health throughout the DMS.
The epidemiology is also different for military medical centres, where staff see significantly higher numbers of patients with musculoskeletal injuries and fewer patients with chronic conditions.
Summary of findings
Figure 1 shows the overall ratings for first comprehensive inspections of medical centres in Year 5, which we determine by aggregating ratings for the five key questions.
Figure 1: Overall ratings for medical centres in Year 5
Numbers of services by rating
- 3 were rated overall as outstanding
- 5 were rated overall as good
- 5 were rated overall as requires improvement
- 1 was rated overall as inadequate
Two overseas medical centres were not rated as they were pilot assessments led by DMSR using an entirely virtual approach.
Ratings by key question for medical centres
In Year 5, we rated all but one medical centre as good for the caring key question and all medical centres were rated as either good or outstanding for being responsive. As we have seen throughout the programme so far, any problems are more often related to the centre’s approach to safety and how well the centre is led and managed. We found fewer concerns about the effectiveness of care and treatment, although we had significant concerns at one medical centre, which we escalated to DMSR for mitigating action.
Three of the medical centres we inspected for the first time in Year 5 were rated as outstanding in the well-led key question. This demonstrates that, in some areas, leaders are learning from the systems and approaches of others in order to deliver care that exceeds the baseline standards. Figure 2 shows ratings for medical centres in Year 5 for each key question.
Figure 2: Ratings for medical centres by key question in Year 5
Figure 3 shows the medical centres we inspected for the first time in Year 5 and the ratings awarded.
Figure 3: First inspections of medical centres in Year 5
| Service | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| Chilwell Medical Centre | Good | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Hereford Medical Centre | Good | Outstanding | Good | Outstanding | Outstanding | Outstanding |
| Kinloss Medical Centre | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
| London Medical Centre | Requires improvement | Good | Good | Good | Good | Good |
| Leconfield Medical Centre | Good | Good | Good | Good | Good | Good |
| Lyneham Medical Centre | Requires improvement | Good | Good | Outstanding | Good | Good |
| Minley Medical Centre | Good | Good | Good | Good | Good | Good |
| Nelson Medical Centre | Inadequate | Inadequate | Good | Good | Requires improvement | Inadequate |
| Poole Medical Centre | Good | Good | Good | Outstanding | Outstanding | Outstanding |
| Southwick Park Medical Centre | Requires improvement | Good | Requires improvement | Good | Requires improvement | Requires improvement |
| Stonehouse Medical Centre | Good | Outstanding | Good | Outstanding | Outstanding | Outstanding |
| Thorney Island Medical Centre | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Wimbish Medical Centre | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Wattisham Medical Centre | Good | Good | Good | Good | Good | Good |
- Brunei Medical Centre: DMSR-led overseas assessments – not rated or published
- Kenya Medical Centre: DMSR-led overseas assessments – not rated or published
- Coningsby Pre-hospital emergency care: Pilot halted
- Nelson urgent care: Pilot halted
Safe key question
A safe service ensures that patients are protected from abuse and avoidable harm through robust systems and processes that enable staff to assess and mitigate risk and see problems before they happen. A key indicator of the safety of a medical centre is a willingness to report safety incidents and be actively involved in learning from them to drive improvement – both within and outside the medical centre.
In Year 5, half of the medical centres inspected for the first time were rated as good for the safe key question. However, as in Years 1-4 of the programme, overall performance for safety is the poorest of all the five key questions, as half were rated as either inadequate or requires improvement. Although we have noted clear improvements in some safety-related areas, some of the issues found in Years 1 to 4 of this inspection programme were raised again throughout Year 5. This continues to call into question the capacity of Defence Medical Services to acknowledge and implement organisational learning relating to safe care and treatment.
There also continues to be a clear link between a lower rating for leadership (well-led) and a lower rating for safety. In Year 5 we recognised some improvements in areas of concern from the previous four years, but we highlighted some common areas for improvement across medical centres.
Safe levels of staffing
As noted in previous annual reports, Defence Medical Services have yet to undertake a comprehensive baseline assessment of the staffing establishment and skills mix that is necessary to deliver safe care within each of its care services. It is outside the remit of the individual service to decide the baseline requirement for its staffing.
Across the five years of this programme, we have consistently identified concerns around shortages in the workforce and the resulting challenges in delivering safe and effective care. Services with poorer ratings tend to have more vacancies and posts that have not been covered by locums. Healthcare teams face staffing gaps when military healthcare staff are deployed, sometimes at short notice, on operational duty and Navy, Army or RAF tasks. This, together with the lack of available civilian and locum staff, means that some services struggle to deliver continuity of service. Specialist staff are not always being placed optimally to address the needs of patient populations. Over half of DPHC healthcare staff are civilian, whose terms and conditions of service do not allow easy redeployment to areas of high need. Additionally, access to training is sometimes a barrier to ensuring an appropriate mix of skills across medical centres at all times.
Information systems
DPHC does not currently have an information system that provides a comprehensive suite of performance indicators across its medical services as recommended in guidance from the National Institute for Health and Care Excellence (NICE).
Across this inspection programme, and in previous annual reports, we have indicated concerns with the completeness and accuracy of patient records at some services:
- The accuracy of Read coding is variable. There is no agreed listing of codes to be used, no agreed standards and DPHC-wide policy for staff to work to and no comprehensive audit programme to ensure improvements in coding across the board.
- Medical centres do not own a comprehensive suite of clinical searches to quantify and provide robust evidence around the safety, quality and effectiveness of care.
- Clinical diagnoses can be unclear and hidden within numerous screens, resulting at times in summarisation deficits.
- There are mutiple clinical templates (written in isolation from policy). This inconsistency in approach leads to coding issues and gaps in reviews for some patients.
There are specific issues around the interface between the Defence Medical Information Capability Programme (DMICP) architecture, DMICP Fixed, Fixed Overseas, Maritime and DMICP Deployed. Maintaining accountable oversight of patients who are deployed is challenging, particularly those with a chronic condition, when they move between several versions of the clinical recording system.
Firewall restrictions create challenges for medical centre staff:
- They do not have access to Integrated Clinical Environment (ICE) order communications software, which supports multiple diagnostic specialities including pathology, radiology, cardiology and endoscopy. Therefore pathology and radiology results are not easily available to military medical centres and this means using work-arounds, which introduce an additional level of risk
- They cannot receive electronic discharge letters
- They cannot easily transfer records to NHS services when patients leave military service.
In Year 5, some practices continued to alert us to failures in IT networks and power. In some cases, these resulted in extended periods without access to the military patient records system. Where this has happened, in line with policy, clinical staff have only seen patients with urgent needs and delayed seeing patients at routine appointments until access to patient records was restored. There are clear risks around delaying appointments and seeing patients without any access to their records.
Managing high-risk medicines
In Year 5 we found issues with the management of high-risk medicines at four medical centres inspected for the first time. Key concerns included:
- inaccurate Read coding and gaps in applying alerts to some patients’ clinical records that resulted in them taking a high-risk medicine without being consistently monitored and reviewed
- lack of clarity around shared care arrangements for some patients.
Effective key question
By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. An effective medical centre routinely reviews the effectiveness and appropriateness of its care as part of quality improvement. When care and support is effective, people have their needs assessed and their care and treatment is delivered in line with current legislation, standards and evidence-based guidance.
Of the medical centres inspected for the first time in Year 5:
- 58% were rated as good for the effective key question
- 14% were rated as outstanding
- 21% were rated as requires improvement
- 7% were rated as inadequate.
We continued to identify concerns relating to:
- ensuring that all staff had received training relevant to their role
- assessing patients and providing care and treatment in line with national standards and guidance, supported by clear clinical pathways and protocols
- peer review, competency checks and clinical supervision to ensure staff are adequately supported to deliver effective patient care
- making best use of the DMICP patient records system to facilitate clinical searches, assure recall programmes and monitor performance
- delivering a rolling programme of work to continuously improve patient outcomes.
Caring key question
A caring medical centre puts its patients at the heart of each service it provides. Confidentiality is particularly significant in military settings as clinicians provide occupational health support to military patients alongside meeting their health and welfare needs.
As well as observing how staff interact with patients, we base our judgements on patient feedback from comment cards, interviews with patients and data from the practice’s own patient surveys.
As in previous years, we found that the vast majority (93%) of the 14 medical centres inspected for the first time in Year 5 provided caring services to their patients. In previous years, performance for the caring key question was the best, but this changed to the responsive key question in Year 5. Building on improvements delivered in Years 1 to 4, staff continued to proactively identify and support those patients who are carers. For example, providing links with carers’ organisations and ensuring that the carer’s emotional and healthcare needs are met.
In one centre we found room for improvement because of the ageing infrastructure, as it allowed sounds to travel between consulting rooms and corridors, meaning patient confidentiality and privacy were not adequately protected.
Responsive key question
Good quality care is organised so that it responds to, and meets, the needs of the practice’s local population. This includes access to appointments and services, choice and continuity of care and meeting the needs of different people, including those in vulnerable circumstances.
DPHC has yet to undertake a comprehensive system-wide baseline assessment of the needs of its patient population as a tool for ensuring that services are fully meeting needs. However, some individual medical centres have carried out extensive work to ensure that they understand the needs of their patients.
In Year 5, 29% of medical centres were rated as outstanding for providing a responsive service and 71% were rated as good. We made no recommendations in this area.
Where we judged care to be good, medical centres understood the needs of their patient population. They had gathered feedback from patients and staff and used this knowledge to ensure that care was convenient and accessible. We found that medical centres offered longer appointments to patients who needed them, and that both staff and patients were clear about when home visits were appropriate.
Responsive medical centres anticipated the unmet needs of patients and sought to address them, for example, giving information to all patients on how to get advice and support with domestic abuse, concealed pregnancy, fabricated illness, child sexual exploitation and female genital mutilation. Responsive medical centres worked in close partnership with rehabilitation facilities to enable timely access to physiotherapy and exercise rehabilitation. They also worked with a number of internal and external stakeholders to identify and meet the needs of personnel who were being medically discharged, and military veterans who were in the surrounding communities.
Well-led key question
We looked at governance arrangements, culture, leadership capacity, vision and strategy, managing risks, issues and performance, and continuous improvement under this key question. As we find in all types of health and care services, poor performance under the well-led key question affects all areas – particularly the safety and effectiveness of care and treatment.
In Year 5, of the medical centres inspected for the first time:
- 21% were rated as outstanding for the well-led key question
- 36% were rated as good
- 43% were rated as requires improvement.
We found examples of outstanding leadership in three medical centres. Key to their success was:
- a strong governance framework that staff understood and could deliver against
- visible leadership
- consistent communications
- a collaborative team approach to promote learning and innovation.
Medical centres rated as outstanding fostered a culture where challenge and transparency allowed teams to fulfil their duty of candour. Outstanding leadership focuses not only on the decisions and work carried out in a medical centre, but it encourages and enables partnership working with internal and external stakeholders to deliver meaningful improvements for patients. Staff in outstanding medical centres had the capacity, experience and skillset to lead, teams were resilient, and deputies were able to support during periods of high demand or where key staff were deployed.
However, there are still several common themes that contribute to the need to improve the quality of leadership.
Leadership capacity
In a small number of medical centres inspected for the first time, senior staff had been deployed at short notice. This left gaps in local leadership and sometimes governance systems were not sufficiently mature and embedded for the remaining staff team to provide a seamless service. Across the five years of inspections, we have consistently found that the medical centres that collaborate, affiliate, and share resources are more resilient to overcome challenges and are more likely to deliver consistently good care.
Effective clinical leadership
The capacity and capability for clinical leadership varies vastly and depends largely on the personal experience and continuity of service of the individuals in post at any one time. Medical centre staff cannot access central training around risk management, good governance, quality improvement, clinical audit, clinical leadership and managing clinical performance. There is no set baseline training for practice managers, and some have no previous experience of managing a practice, with little or no training – instead they are asked to train on the job. Without basic leadership training, it is difficult for leaders in medical centres to develop and improve their approach to clinical leadership.
Good governance
Governance systems are not always effective and do not support practices to deliver consistently high-quality services. We identified the following common issues in Year 5:
- staff are not always working to central policy and procedure, sometimes leading to inconsistency in care
- there are not always planned improvement programmes focused around delivering meaningful and improved outcomes for patients
- practices do not always understand and monitor their own performance
- the arrangements to identify, record, and manage risks and issues, and implement mitigating actions, are sometimes ineffective
- meetings can be ineffective, either due to poor attendance, irregularity or poor agenda management, and discussions do not always include standing agenda items, recent clinical guidance, patient safety alerts and risk registers, so actions are overlooked.
Reflections on an outstanding service: The leadership contribution at DMS Hereford
When we visited this site, we were struck by the pride of the leaders when providing this integrated medical and rehabilitation service. We saw that the team genuinely cared about the patients under their care. Many patients have complex needs as a result of musculoskeletal injuries from training and service, along with mental health needs. As well as providing the best care for military personnel, leaders also strive to give the best supportive care and leadership for their medical team.
We identified six characteristics that shone through to make this leadership outstanding:
- Continuity of the leadership team - being mainly civilian enables the team to make an impact: the practice manager, lead clinician and the lead nurse had all been working in Hereford for over nine years.
- Providing a holistic service - this is coordinated through multi-disciplinary team working with weekly meetings. It includes mental health, occupational therapy, physiotherapists, and specialist medical staff working at scale through a flexible and integrated team. As well as treating patients, they provide ‘up-stream’ prevention, education and early-stage intervention. They know their patients and reach out to them and proactively help.
- Creating regular and frequent all-staff timeouts - this is seen as priority time for all staff where quality improvement is at the heart of the work. These sessions develop and shape the practice plan that sets out the programme of work and priorities, where staff spend time connecting and communicating and generate ideas as a team.
- Proud to adopt from others - all the leaders shared how they have learned from other medical centres and if others are doing something well, they have openly reproduced it.
- Support from the regional team - especially around good governance and continually being able to benchmark their service.
- An open, caring and transparent culture - all the team appreciate this culture, where they can work flexibly. Staff commented on how they cared about each other, checking in and supporting each other. They described the culture as being infectious as they were all enthusiastic about team cohesion through coffee mornings, bringing cakes to work, weekly training, team building and clinical supervision.
Comments from members of the team show how the leadership has encouraged team working and dedication to the service:
"I am x in the team – it doesn’t matter which grade I am, ranks aren’t used here, there is no uniform, everyone is on first name terms, I am valued for my contribution, I feel respected”.
“We have a passion to work here, there is great team working and we all get on."
Improvement on re-inspection
Where we identify shortfalls in the quality of care, we return to re-inspect to ensure that the service has made sufficient improvement. In Year 5 we re-inspected 17 medical centres (figure 4). Of these, 13 were re-inspected for the first time, three were re-inspected for the third time and one for the fourth time.
Of the 17 services we re-inspected, 13 demonstrated sufficient positive improvement to confirm that the quality of care had improved.
Figure 4: Outcomes of re-inspections of medical centres by key question in Year 5
Boulmer Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Good | Requires improvement | Requires improvement | Requires improvement |
| 2nd inspection | Inadequate | Inadequate | No rating | Requires improvement | Inadequate | Inadequate |
| 3rd inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
| 4th inspection | Good | Good | Good | Good | Good | Good |
Bramcote Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Requires improvement | Good | Good | Good | Requires improvement |
| 2nd inspection | Requires improvement | Good | Good | Good | Good | Good |
Brawdy Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Inadequate | Good | Requires improvement | Inadequate | Inadequate |
| 2nd inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 3rd inspection | Requires improvement | Good | Good | Good | Good | Good |
Brecon Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Requires improvement | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Catterick ITC Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Inadequate | Requires improvement | Good | Requires improvement | Inadequate |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Colchester Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Inadequate | Requires improvement | Inadequate | Inadequate |
| 2nd inspection | Requires improvement | Good | Good | Good | Good | Good |
| 3rd inspection | Good | - | - | - | - | - |
Cottesmore Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Inadequate | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Honington Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Middle Wallop Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Good | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Newcastle Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Good | Good | Inadequate | Inadequate |
| 2nd inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
Norton Manor Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Odiham Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Outstanding | Good | Good | Good | Good |
Swanton Morely Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
Tidworth Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Wittering Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Woodbridge Medical Centre
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Inadequate | Requires improvement | Good | Requires improvement | Inadequate | Inadequate |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
Following a first or second (and in one case a third) follow-up inspection, almost all services responded well to our inspection findings and engaged with CQC, DMSR and DPHC to understand what they could do to improve. Some practices had received support from regional teams to create and deliver improvement action plans and additional staff resource had been provided to bolster improvement across some teams. We also saw evidence of medical centres seeking support and guidance from high-performing teams and working collaboratively to deliver positive solutions. Five medical centres will require a further re-inspection in Year 6 as there are still areas that require improvement.
Three medical centres had not made sufficient improvement in two key questions or more and requirements remained around:
- safeguarding arrangements
- infrastructure, facilities, cleaning arrangements and clinical waste management
- staffing levels and skills mix to ensure clinical resilience
- effective systems to support monitoring of patients with a long-term condition
- governance systems to manage risk and ensure consistency in care standards
- consistent use of central standard operating procedures, policies and protocols
- medicines management
- training oversight for regimental staff working in DPHC facilities.
We will continue to follow up the recommendations made during Year 5 to ensure that the services implement improvements for patients.
Dental services
We inspect only 10% of high street dental services each year and we do not formally rate these providers. We take the same approach in the DMS inspections – although there is no rating, we judge whether the service is meeting standards and we make recommendations in the inspection report.
In Year 5, DMSR asked CQC to carry out first comprehensive inspections at 12 dental centres. We found that all were meeting the regulations for all key questions.
- Aldershot Dental Centre - all standards met for all key questions
- Colchester Dental Centre - all standards met for all key questions
- Cranwell Dental Centre - all standards met for all key questions
- Culdrose Dental Centre - all standards met for all key questions
- Kinloss Dental Centre - all standards met for all key questions
- Larkhill Dental Centre - all standards met for all key questions
- Lichfield Dental Centre - all standards met for all key questions
- London Dental Centre - all standards met for all key questions
- Lossiemouth Dental Centre - all standards met for all key questions
- Newcastle Dental Centre - all standards met for all key questions
- Poole Dental Centre - all standards met for all key questions
- Yeovilton Dental Centre - all standards met for all key questions
We noted the maturity of governance processes across dental services. The dental service has been operating as a joint (RAF, Navy and Army) service for 25 years and the benefits of operating together are clear, with standardised operating procedures used consistently and centralised guidance. There is also a strong focus on preventative health promotion work through delivering Project MOLAR/MOLAIR, a treatment strategy used to improve the dental health of personnel entering military service. The project ensures that recruits have protected time for dental assessment and treatment during their training.
However, we have noted a common issue that sits outside the influence and control of dental centre teams and which we have therefore escalated to DMSR to secure a system-wide solution. Station teams are often responsible for monitoring water safety and so have a remit to ensure that water temperatures sit within certain parameters to minimise the risk of Legionella in the water system. But the results of these checks are often not shared with dental teams. Furthermore, on more than one occasion, we have found that where water temperatures have strayed outside an acceptable range, there has been no mitigating action and the dental centre team were not informed.
DPHC should ensure water temperature checks are routinely shared with the practice so that they have assurance that the checks are being carried out and that temperatures are within the parameters as outlined in HTM 01-05 (chapter 19).
Improvement on re-inspection of dental centres
We also re-inspected one dental centre in Year 5 to follow up recommendations made previously.
Since our previous inspection, the regional team had worked with the team at Harrogate Dental Centre to ensure that there were sufficient staff with the right skills mix to meet patient care requirements. All standards are now met.
Additional nursing staff, a hygienist and a full-time practice manager had come into post. The team confirmed that the staffing establishment and skills mix were now appropriate to meet the dental needs of the patient population, to maximise oral health opportunities and to deliver Project MOLAR to improve the dental health of personnel entering the military.
Defence community mental health services
Defence medical services provide occupational mental health assessment, advice and treatment through a network of departments of community mental health (DCMHs) and mental health teams. The aim of the service is balanced between the needs of defence and the needs of the individual, to promote the wellbeing and recovery of the individual in all respects of their occupational role and to maintain the fighting effectiveness of the Armed Services.
We began a programme of inspection of the departments of community mental health in October 2017. All DCMHs have now received an initial first inspection as part of this programme and we have developed a clear understanding of the challenges faced by the services and the areas of practice that need to improve.
First inspections in 2021/22
In 2021/22, we carried out first inspections of three DCMHs based at Donnington, London and Leeming (figure 5), including associated mental health teams at Lisburn, Preston and Hereford.
Figure 5: First inspections of community mental health services in Year 5
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| Donnington | Not yet published | Not yet published | Not yet published | Not yet published | Not yet published | Not yet published |
| Leeming | Good | Good | Good | Good | Outstanding | Good |
| London | Good | Good | Good | Good | Requires improvement | Good |
Re-inspections in 2021/22
Where we identify shortfalls in the quality of care, we return to re-inspect to ensure that the service has made sufficient improvement. During Year 5, We re-inspected three services where we had previously rated some key questions as requires improvement: DCMH Scotland, DCMH Plymouth and DCMH Bulford (which was previously known as DCMH Tidworth before it relocated). We have seen significant improvement and previously identified concerns were being addressed. All the re-inspected services are now rated as good or outstanding in all key questions figure 6).
Figure 6: Re-inspections of community mental health services in Year 5
DCMH Scotland
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Good | Good | Inadequate | Inadequate | Inadequate |
| 2nd inspection | Good | Good | Good | Requires improvement | Requires improvement | Requires improvement |
| 3rd inspection | Good | Good | Good | Good | Good | Good |
DCMH Bulford
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Outstanding | Good |
DCMH Plymouth
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| 1st inspection | Requires improvement | Good | Good | Requires improvement | Good | Requires improvement |
| 2nd inspection | Good | Good | Good | Good | Good | Good |
A positive move for DCMH Bulford
In July 2019, we inspected DCMH Tidworth for the first time. The safe and well-led key questions were rated as requires improvement, and the service required improvement overall. At the initial inspection we had found:
- concerns about the management of referral pathways, clinical risk management processes, following up patients who did not attend, clinical record-keeping and multidisciplinary decision-making, incident reporting, and leadership
- a lack of administration staff, which increased clinicians’ workload as they needed to cover reception and complete administrative tasks
- no clear process to manage clinicians’ caseloads in their absence
- no access to accurate information about performance to support governance and improvement
- poor staff morale before the inspection.
The team moved to a new purpose-built facility at Bulford Camp. When we returned to the service in July 2021, all areas of previous concern had improved and there were some areas of outstanding practice.
- There was clear and accountable leadership at DCMH Bulford, and staff reported that morale was very good.
- An overarching governance framework supported the delivery of the service, considered performance and ensured continuous learning. Effective systems and processes had been set up to capture governance and performance information. Potential risks that we found had been captured in the risk logs and the common assurance framework and included detailed mitigation and action plans.
- The team had implemented systems and processes to ensure clear oversight of clinical risk to patients.
- Despite an increase in caseload, the team had met the response target for urgent and routine referrals and waiting lists for treatment had reduced.
- Staff had a good awareness of safeguarding procedures and practice. They reported all relevant events, which were investigated appropriately, and the learning from these was used to drive a safety culture.
- A range of quality improvement projects were enhancing patient care and the team demonstrated some areas of outstanding practice.
- The well-designed single healthcare facility fully met health and safety standards and contributed to patients’ dignity and wellbeing.
Following this inspection, DCMH Bulford was re-rated as good overall and outstanding for the well led-key question.
Safe key question
Safe community mental health services ensure that people are protected by a strong comprehensive safety system, with a focus on openness, transparency and learning when things go wrong.
All the services inspected during 2021/22 were delivering safe care.
Services managed clinical risks appropriately and teams had processes to share concerns about known patients in crisis, or whose risks had increased.
There were enough staff to meet patients’ needs and to ensure they did not wait too long to be assessed or to receive treatment. Where there were any gaps in posts these had usually been filled by long-term agency staff. However, we noted that some services had unfilled psychiatrist posts and although the services had remained safe through external support, we were concerned about the long-term impact.
Generally, we saw a better standard of infrastructure. At Leeming and Plymouth, although the team’s bases did not fully meet accessibility standards, staff had made arrangements to ensure that people with a disability could be seen at an alternative facility. All facilities were clean, with good decoration and prompt maintenance. All services had risk-assessed the environment and made appropriate arrangements to mitigate potential safety risks to patients.
While based at Tidworth, the team had needed to work across three separate buildings to ensure sufficient and appropriate space for treatment. However, the team had since moved to a purpose-built healthcare facility at Bulford Camp. The building was built to NHS standards and was well-decorated and equipped, and fully accessible to anyone with a physical disability.
We are also pleased to report that all our previous concerns about the facilities used by the team in Scotland have been addressed.
All services controlled the risk of infection well and had appropriate systems based on national guidance to manage the risks associated with COVID 19. This included the accessibility and use of personal protective equipment (PPE) and COVID testing.
During Year 5, we found that all our previous concerns around reporting and investigating significant incidents had been improved, and that teams had developed mechanisms to share learning with staff.
Effective key question
Effective community mental health services ensure that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
All the services inspected during this period were offering effective care.
Teams comprised a full range of mental health disciplines working under the clinical leadership of either a consultant psychiatrist or psychologist. All teams included skilled and experienced staff who worked in partnership with other agencies to manage and assess patients’ needs and risks. Staff had access to appropriate supervision, case management and appraisal, and could access developmental training.
Record keeping was of a high standard, and we found that treatment plans were discussed with and agreed with patients.
Formal care plans were in place at all services and were usually holistic and person-centred. Care and treatment plans were reviewed regularly in weekly multidisciplinary team meetings and most patients we spoke with confirmed they had received copies of their care plans, which were updated frequently and were useful.
Patients could access a wide range of psychological therapies as recommended in NICE guidelines. Clinicians were aware of current evidence-based guidance and standards and used this to guide their practice. The teams used a range of outcome measures throughout and following treatment. These mainly indicated improved outcomes following treatment.
Teams provided many positive examples where partnerships with other organisations had jointly helped patients to remain in the military.
Caring key question
Caring community mental health services ensure that people are supported, treated with dignity and respect, and are involved as partners in their care.
As in previous years, all the services inspected during this period were providing good care.
Staff showed us that they wanted to provide high-quality care. We observed some very positive examples of staff providing practical and emotional support to people at all services visited.
Patients said they were well-supported, and that staff were kind and enabled them to get better. There was good patient satisfaction demonstrated by mostly positive patient experience survey results and the feedback we received from the 47 patients we spoke with was almost unanimously positive about the attitude of staff and the support they received.
Responsive key question
Responsive community mental health services ensure that services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care.
All the services visited provided responsive care.
Throughout the pandemic, staff in all services had mainly worked at home to minimise risk but had continued to offer both virtual and face-to-face appointments where necessary. Patients told us they had found virtual appointments extremely welcome as this had cut down on travel to appointments and had allowed greater flexibility. Following the pandemic, teams were increasing their office presence to allow greater access to face-to-face appointments but continued to offer virtual appointments as needed.
Teams had developed systems to respond to demand in the service. Generally, all teams were meeting targets for response to both urgent and routine referrals and waiting times were reduced on previous years.
The team in Scotland had developed an effective ‘hub and spoke’ model to ensure localised and efficient delivery of care. All referrals were managed through a central source, with assessments coordinated by a nominated referral lead for each team to ensure a localised response and continuity. Where capacity was stretched, members of other teams would deliver care were they had capacity. This ensured equal access across Scotland.
At Leeming, the team had volunteered to lead an outpatient service pilot project working with two other DCMHs to improve access to the service and treatment. This had led to smaller waiting lists for psychology across the services.
All teams had systems for handling complaints and concerns. Most patients we spoke with during inspections knew how to complain and felt that they would be listened to if they needed to complain. Learning was captured from complaints and usually shared with staff at team and governance meetings.
Well-led key question
Well-led community mental health services have strong leadership, management and governance, to ensure the delivery of high-quality and person-centred care, to support learning and innovation, and to promote an open and fair culture.
Overall performance for the well-led key question was generally positive this year – an improvement on findings in previous years. Most services inspected were well-led and we found outstanding leadership and very good staff morale at Leeming and Bulford. DCMH Leeming had a clear and effective management structure. Leaders worked very well together and demonstrated high levels of experience, capability and resourcefulness to deliver safe and effective care to patients.
However, at DCMH London, we found gaps in key leadership roles that the regional management team had not fully addressed. While staff acting into these roles were working hard to lead the team, management capacity was affecting the delivery of the service.
Staff at most services reported that their management team was approachable and supportive of their work and staff morale was good and improving. We saw in all services that staff wanted to do a good job and were positive and clear about their own role in delivering the vision and values of the service. Most staff felt engaged in the development of the service.
Management systems and governance structures ensured that most risks that we found on previous inspections had been captured in the risk and issues logs and reflected in the common assurance framework.
Most teams had undertaken quality improvement initiatives. To help address capacity issues for the regional occupational health team, the management team at DCMH Leeming had set up monthly engagement meetings to share patient information and facilitate a smoother and faster discharge for patients who were leaving the military. Following an incident reported through the ASER system, the clinical lead at Bulford offered training to medics working across primary care practices about applying the Mental Health Act and managing patients during a crisis. This session was extremely well attended and received positive feedback. The team in London had developed a ‘single page staff management system’, which provides a single reference point for staff and managers to quickly improve training compliance and access to human resources information.
Regional rehabilitation units
Regional rehabilitation units (RRUs) are provided by the Defence Primary Healthcare (DPHC) Unit. They deliver intermediate rehabilitation within the Defence Medical Rehabilitation Programme (DMRP).
During 2021/22, we carried out two first inspections. Both were rated as good overall.
Figure 7: First inspections of regional rehabilitation units in Year 5
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| Halton | Good | Good | Good | Good | Good | Good |
| Plymouth | Good | Good | Good | Good | Good | Good |
We also completed two follow-up inspections at RRU Catterick and at RRU Bulford (this site has replaced RRU Tidworth).
Figure 8: Re-inspections of regional rehabilitation units in Year 5
| Safe | Effective | Caring | Responsive | Well-led | Overall | |
|---|---|---|---|---|---|---|
| Catterick | Good | Good | Good | Good | Good | Good |
| Bulford | Good | Good | Good | Good | Good | Good |
During the next year (2022/23), we will carry out a first inspection at RRU Aldergrove as well as one of the units that we previously inspected but did not have the powers to rate. This will enable us to test that our approach to rating was effective once all units have had a first inspection before we complete the RRU programme.
Safe key question
We found a concern at RRU Halton, where not all the estates and facilities were fully fit for purpose and data collected on outcomes was not fully used to improve the quality of service.
Effective key question
Patients’ clinical needs were assessed in line with national clinical standards and their care was planned in person with them. A multidisciplinary team of medical and physiotherapy staff, and exercise rehabilitation instructors carried out the assessment, which included podiatry staff where necessary.
We saw that multidisciplinary team working was particularly effective and embedded in all the regional rehabilitation units inspected. Most units used outcome measures to assess the effectiveness of treatment as well as structured formal course assessments that involved patients.
Caring key question
All interactions we observed between staff and patients were appropriate. Staff demonstrated empathy towards patients and took appropriate steps to maintain their privacy and dignity, including chaperones, where necessary. Patient satisfaction was generally very high. There were a number of formal and informal opportunities for patients to provide feedback, and unit staff actively encouraged this. The patients we spoke with all indicated that they were involved in decisions about their care. There were very few complaints made at any of the units.
Responsive key question
The rehabilitation units provide bespoke occupational services to support injured service personnel to achieve functional fitness. Access to services was good. Referral pathways worked between the primary care rehabilitation facilities and the regional rehabilitation units. The majority of units met their access targets, and facilities had the correct equipment to provide rehabilitation.
Well-led key question
Leadership was generally good, with staff engaged in the development and leadership of the units. Staff groups were cohesive and worked well together to provide a high-quality service. Leaders were visible and all staff were encouraged to share their views and take part in developing the service. The governance arrangements included clear lines of accountability and reporting. Quality improvement was encouraged, both from feedback from patients as well as audit outcomes.
However, we found some concerns at RRU Halton in terms of support for the interim leadership team.
Conclusion
At the end of the fifth year of our inspections, we can see mostly positive change within DMS services. Most issues we identified with the quality of care have been addressed and services have improved.
Our inspections highlight a number of internal factors that contribute to high-quality care, as well as factors that may inhibit it. Military personnel and entitled dependants continue to receive prompt access to almost all services, and most have a very short wait to see a healthcare professional. The majority of staff working in medical facilities engage their specialist skillset to balance delivering effective health care alongside meeting people’s individual needs.
However, a small number of medical centres have ongoing requirements. Where we have seen examples of poor-quality care, the contributory factors range from applying policy and procedure inconsistently, gaps in workforce management, poor infrastructure, and information management concerns that inhibit effective recall of patients with a long-term condition.
Where we found concerns on inspection, our recommendations were designed to improve care to benefit both patients and healthcare staff. DMSR has taken enforcement action where we have escalated concerns.
In Year 5, we re-inspected a number of services to follow up recommendations from first, second (and in one case a third) inspections. These have generally shown positive improvement across all service types, demonstrating organisational learning and improved quality. Sharing best practice and innovation across some services has resulted in significant benefits for staff and patients. However, there is scope to broaden this shared learning to benefit the whole patient population.
DMS staff remained substantially involved both in responding to the needs of their own patients as a result of the COVID-19 pandemic and also in supporting the NHS response to the requirements of the UK population in 2021/22. DPHC staff have been deployed to deliver Military Aid to the Civil Authority (MACA). This has seen clinical teams and other military personnel supporting public services across the UK to assist with the response to COVID-19. This substantial effort is acknowledged for its significant impact across the UK population.