Unity Healthcare

Christmas Maltings, Clements & Kedington Surgery was previously inspected on 27 January 2019. The practice was rated inadequate for providing effective and well-led services, requires improvement for providing safe and responsive services and was rated good for providing caring services. This gave the practice an overall rating of inadequate and the practice was placed into special measures. The practice was issued with a warning notice for Regulation 17, Good governance.

We carried out an announced comprehensive inspection on 21 August 2019 following six months in special measures.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We rated the practice as good for providing safe services because:

• Improvements had been made in relation to information to deliver safe care and treatment. On the day of the inspection we saw evidence of appropriate safeguarding referrals.
• There was clear and embedded oversight of all safety alerts received in the practice. We saw a good audit trail for this process.
• The practice had streamlined their records for safety systems. They had reduced the number of different agencies attending the practice for calibration of equipment.
• the system used to monitor repeat medicines was consistent and recorded to allow easy monitoring.

We rated the practice as requires improvement for providing effective services. Three population groups, people with long term conditions, families, children and young people and working age adults (including those recently retired and students) were rated requires improvement. These ratings were given because:

• Although the 2018/2019 QOF data showed an improvement, some performance remained below the local and national averages. We saw a comprehensive long-term action plan the practice were using to continue and sustain these improvements.
• The practice was aware their cervical screening rate was lower than the national average. They had reviewed performance in relation to cancer screening and reviews and were in the process of inviting patients in for appointments.
• Three out of four of the child immunisations were below the World Health Organisation target of 95%. The practice proactively educated mums that attended the baby clinics and offered appointments opportunistically. However, at the time of our inspection the practice was unable to demonstrate improvement in the Public Health England data.

We rated the practice as requires improvement for providing caring services because:

• The data from the national GP patient survey in relation to patient’s overall experience of the GP practice had reduced further, since our previous inspection.

We rated the practice and all population groups as inadequate for providing responsive services because:

• Although the practice had made some changes to try to improve access there was no improvement in the national GP patient survey results published in July 2019 and in six out of nine indicators, patient satisfaction had reduced. The practice was not able to evidence patient satisfaction regarding access had improved. This applies to all patients and therefore all population groups.

We rated the practice as requires improvement for providing well led services because:

• Some improvements had been made to ensure clinical leadership and oversight was embedded. The competence of clinical staff employed in advanced clinical practice was assessed and monitored. However, feedback from the national GP patient survey and performance in relation to some areas of the Quality and Outcomes Framework remained below CCG and national averages.

The areas where the provider should make improvements are:

• Continue to monitor and improve the uptake of childhood immunisations and cancer review and ensure data is submitted to Public Health England in a timely way.
• Continue to monitor and improve the uptake of cervical screening .
• Continue to embed and sustain the systems and process to ensure patients receive appropriate reviews in a timely manner.
• Continue to review, monitor and improve patient feedback to ensure patients receive timely access to care and treatment.
• Continue to review and reduce prescribing of antibiotics for uncomplicated urinary tract infections.

This practice will remain in special measures for a further six months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

This practice is rated as Inadequate overall. At the previous inspection in August 2018 the

practice was rated as requires improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Christmas Maltings, Clements & Keddington Surgery on 24 January 2019 as part of our inspection of Suffolk GP Federation.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We concluded that:

• Improvements had been made from our previous inspection in August 2018. However, we found a number of new concerns during this inspection.
• Patients were not always able to access care and treatment in a timely way and feedback from patients in relation to accessing the practice was poor. The practice had implemented changes to improve access and were planning to evaluate the impact of these changes.
• Quality Outcomes Framework data was significantly lower than local and national averages for some indicators.
• Patients we spoke with on the day of the inspection and feedback from patient comment cards received demonstrated that patients were positive about the caring nature of staff.
• We found complaints were handled appropriately and within a timely manner.
• Systems and processes did not ensure people were always adequately protected from avoidable harm.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

We rated the practice as requires improvement for providing safe services because:

• We found out of date medicines in the dispensary refrigerator.
• The practice could not evidence up-to-date and accurate children and adult safeguarding registers.
• The practice did not always have oversight of equipment calibration.

We rated the practice as inadequate for providing effective services because:

• The practice did not have an effective system in place to conduct medicine reviews.
• The practice’s 2017/2018 QOF achievement for all long-term conditions was significantly lower than the CCG and England averages. We reviewed unverified data from 2018/2019 and found minimal improvements had been made.
• The practice could not provide evidence to show they were assured of the competence of clinical staff employed in advanced practice. When we reviewed the consultations of clinicians, we found these were not always documented in line with national guidelines.
• We found a number of computer system coding issues which meant we were not assured that patients were always receiving the correct care, treatment and monitoring for their conditions.

We rated the practice as good for providing caring services.

We rated the practice as requires improvement for providing responsive services because:

• Patient satisfaction in relation to accessing the practice was low; results from the GP National Patient Survey was significantly below the CCG and England averages. The practice’s complaints records also supported this. The practice had implemented changes to improve access and were planning to evaluate the impact of these changes. However, it was noted 98% of patients stated that at their last general practice appointment, their needs were met.

We rated the practice as inadequate for providing well led services because:

• Despite Suffolk GP Federation C.I.C having systems and processes in place to try and ensure leadership and governance at the practice, this was not effective as there was a lack of clinical oversight at the practice level.
• The practice could not evidence that risks, issues and performance were managed and could not demonstrate actions taken in response to poor performance such as outcomes for patients with long-term conditions.
• Despite a comprehensive audit programme undertaken by the provider, Suffolk GP Federation C.I.C, the quality improvement methods in place did not ensure risks and performance was effectively managed at the practice.
• The practice could not provide evidence they were assured of the competence of clinical staff employed in advanced practice.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Establish effective systems to record all dispensing errors and near misses to ensure trends can be analysed and action taken to prevent reoccurrence.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am placing this service in 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.

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