Archived: Bath Street Medical Centre

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. We previously carried out an announced comprehensive inspection in June 2017; the practice was rated as inadequate and placed into special measures, with the safe and well-led key questions rated as inadequate. The practice was rated as requires improvement for the effective, caring and responsive key questions.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Bath Street Medical Centre on 4 December 2017 to monitor that the necessary improvements since our last inspection had been made.

At this inspection we found that improvements had been made:

• At the last inspection we found that nurses were operating outside their sphere of competence and a requirement notice was issued. We found that the practice had reviewed the working procedures for all clinical staff, gynaecology and breast examinations were now done solely by a GP.
• The provider had improved the recruitment procedures to include all appropriate checks with the exception of a physical and mental health assessment on staff employed.
• The practice had now signed up to receive all national safety alerts and these were effectively managed by the practice pharmacist.
• Effective systems to capture feedback had been implemented. The feedback was utilised in regular discussion with staff and patients and used to formulate an action plan that identified where further improvements could be made.

Additionally we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice had systems to safeguard children and vulnerable adults from the risk of abuse. Staff demonstrated an awareness of vulnerable patients but the systems required better governance.
• Practice staff were aware of and management acted on their duty of candour appropriately.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. The practice had an effective recall system to ensure patients with long term conditions were offered timely reviews.
• Staff worked with other health and social care professionals to deliver effective care and treatment.
• We saw that staff treated patients with compassion, kindness, dignity and respect. However, the feedback from patients on consultations with a GP was still below local and national averages. The practice were aware and had taken further steps to address this.
• Patients reported that they were able to access care when they needed it. However, the patient feedback regarding access to a GP appointment was below local and national averages.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• Staff we spoke with were aware of the practice’s vision and were aware of their roles in achieving this.

There were areas identified where the provider should make improvements:

• Further improve the arrangements that ensure care and treatment is provided in a safe way to patients. In particular:

• Review the safeguarding procedures to ensure vulnerable adults are highlighted on the clinical system, polices reflect the most recent definitions of abuse and a summary of discussions held at safeguarding meetings are minuted.
• Risk assess the visibility for the patient waiting area in regards to the response to an emergency situation.
• Review the arrangements for induction of new staff.

• Review the prescribing of hypnotics (medicines to relieve anxiety, aid sleep, or have a calming effect) to reduce the rates in line with Clinical Commissioning Group (CCG) and national averages.
• Explore how uptake rates for cervical screening can be further improved.
• Revise the system used to encourage eligible patients to have the meningitis vaccine, for example before attending university for the first time.
• Consider measures to improve the patient feedback on access to GP appointments.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously inspected Bath Street Medical Centre on 26 July 2016. The inspection in July 2016 was a comprehensive follow up inspection, as the practice was originally placed in to special measures under the previous provider in November 2015. Shortly after our inspection, the previous provider had retired from the practice and a salaried GP was appointed as the new principal GP.

As a result of our inspection visit on 26 July 2016, the practice was rated as requires improvement. Specifically, the practice was rated as requires improvement for providing effective and caring services and a requirement notice was issued to the provider. This was because we identified regulatory breaches in relation to regulation 17, Good governance. Furthermore, we identified some areas where the provider must make improvements and additional areas where the provider should improve.

We carried out an announced comprehensive inspection at Bath Street Medical Centre, on 7 June 2017. This inspection was conducted to see if improvements had been made following the previous inspection in 2016. You can read the reports from our previous inspections, by selecting the 'all reports' link for Bath Street Medical Centre on our website at www.cqc.org.uk.

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

• During our inspection the principal GP explained that female patients who declined to be examined by the male GP were referred to the practice nurses to carry out gynaecology examinations and breast examinations. We raised this as a concern during our inspection as the nurses were not trained in these areas and this posed the risk of women receiving false reassurance leading to delayed or missed diagnoses. Members of the management team assured us that they would not continue with this process until nurses completed required training; we received further information shortly after our inspection to confirm that the nurses were scheduled in for breast examination screening on 6 July 2017. We did not receive further information with regards to gynaecological examinations.

• Following our inspection the practice provided evidence of a statement from a secondary care consultant confirming that the nurses spent a day in the breast symptom clinic, observing history taking and breast examinations. The nurses also performed a breast examination whilst supervised in secondary care. As an additional measure the practice was also in the process of appointing a female GP, this would also provide patients with the option of being examined by a female GP.

• We saw that the practice shared learning from significant events, complaints and incidents.

• When we inspected the practice in July 2016 we found that the GPs were not included in multi-disciplinary team meetings and practice meetings. When we returned to the practice most recently we saw minutes of meetings demonstrating that the GPs attended the meetings.

• There was a system in place to monitor action taken in relation to safety alerts; however during our inspection we found that the practice had not signed up to receive all national safety alerts.

• Staff we spoke with said that whilst they felt supported there was not always support in place when reporting concerns in the practice and sometimes staff felt pressured due to busy workloads. Members of the management team advised that the planned recruitment of a non-clinical staff member and increased clinical hours should help to ease the pressure on staff.

• During our most recent inspection we found that the practices carers register had increased to 3%. The practice offered annual reviews and flu vaccinations for anyone who was a carer; there was supportive information in place for carers to take away as well as information available through the practice website.

• The practice performance was below local and national averages for some areas of the national GP Patient survey, such as involvement in planning and making decisions about their care and treatment. Although we saw that some changes had been implemented in relation to the survey, the practice could not demonstrate if these changes had been effective.

• Patient participation group (PPG) feedback indicated that meetings were unstructured and we received mixed feedback with regards to acting on suggestions made by the PPG.

• The practice provided further information and assurance to demonstrate that improvements had been made since our inspection took place. However, we noted that for some areas this approach was reactive. For instance, during our inspection we were provided with unclear and conflicting information from staff across areas such as fire safety; tests and evacuation drills. Following our inspection the practice assured us that a meeting was held with staff to reiterate procedures including fire tests and drills. The improvements made since our inspection took place will be followed up as part of our next inspection.

The areas where the provider must make improvements are:

During our inspection on 7 June 2017 the principal GP explained that female patients who declined to be examined by the male GP were referred to the practice nurses to carry out gynaecology examinations and breast examinations. We raised this as a concern during our inspection as the nurses had not received specific training in these areas.

The Care Quality Commission contacted the provider on 13 July 2017 to request that the practice did not continue with this process until nurses completed required training.

• The provider must ensure that they comply with this arrangement

• Ensure care and treatment is provided in a safe way to patients

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

I am placing this service back in to special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate 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 service 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 by adopting our proposal to remove this location or cancel the provider’s registration.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice