Archived: The Willows Medical Centre

Updated 25 August 2016

The Willows Medical Centre provides primary medical services to approximately 3600 patients through a personal medical services (PMS) contract.

Services are provided from purpose built premises located in Carlton, a suburb of Nottingham. The practice has its own car parking and is accessible by public transport.

The level of deprivation within the practice population is slightly below the national average. The practice had a higher than average number of patients who are 65 years and over.

The practice has one male GP, one long term locum GP (male) and two healthcare assistants (female). The practice does not currently employ a nurse but has support from a locum nurse two half days per week (a total of one day). The clinical team is supported by a practice manager and reception and administrative staff.

The practice opens from 8am to 6.30pm on Monday, from 7.30am to 6.30pm on Tuesday, from 8am to 7.30pm on Wednesday, from 8am to 1pm on Thursday and from 8am to 6.30pm on Friday.

The practice has opted out of providing out of hours services to its own patients. This service is provided by NEMS and accessed via 111.

Updated 25 August 2016

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at The Willows Medical Centre on 6 June 2016. Overall the practice is rated as inadequate.

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example the practice was employing a healthcare assistant to undertake tasks outside of the responsibilities suitable for persons employed in such a role. In addition there was no evidence to demonstrate they had the training and were competent to undertake a number of the tasks allocated to them. In addition, this member of staff was undertaking examinations, assessments and diagnoses of patients in spite of not being a registered or regulated healthcare professional in this country.
• There were not enough staff within the practice to ensure patients were kept safe and to ensure they received treatment from an appropriately qualified member of staff. Staff confirmed they felt there were not enough staff and told us that requests for additional staff had been refused.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements. The provider did not have arrangements in place to ensure safe, high quality care was provided to patients and had knowingly employed a healthcare assistant to undertake medical examinations which were outside the scope of the role and for which the individual was not registered or regulated.
• There was a culture of fear and blame within the practice and we were not assured that all significant events were reported and used as opportunities to improve safety within the practice.
• We found that the practice did not have effective system in place to check the expiry dates of medical consumables. For example we found a large amount of out of date medical consumables including dressings, boric acid urine sample pots, histological specimen pots and over 100 blood collection tubes.
• Data from the Quality and Outcomes Framework (QOF) showed the practice was performing above local and national averages.
• Evidence from the clinical system showed that care and treatment was not being delivered in line with local and national guidelines.
• The clinical computer system within the practice showed that non-clinical staff were recorded as undertaking medication reviews for patients meaning we could not be assured that patients were having a proper medical review of their long term conditions by an appropriately qualified healthcare professional. As these reviews were recorded on the system as completed these patients would not be recalled.
• There was a lack of clarity amongst practice staff regarding the appointment system with confusion over the availability of pre bookable appointments. Patients told us they found it difficult to book appointments in advance and a review of the appointment systems showed no appointments available to pre book.
• The majority of patients said they were treated with compassion, dignity and respect. However, data from the national GP patient survey showed 51% of patients said they would recommend this GP practice to someone new to the local area compared to the CCG average of 79% and the national average of 78%.
• Staff were not supported or valued within the practice and did not have adequate supervision in their roles. Staff had not received appraisals in the last 12 months.

The areas where the provider must make improvements are:

Provide safe care and treatment to patients by assessing risks to their health, safety and welfare and do all that is possible to mitigate this by;

• Ensuring only staff qualified and registered with the appropriate professional body are providing medical care and treatment to patients.
• Putting systems in place to ensure care and treatment is delivered in line with national guidance and best practice guidelines.
• Improving the management of medicines alerts to ensure action is taken where necessary to keep patient safe.
• Improving arrangements to review medicines prescribed to patients and ensure this is role is always undertaken by suitably qualified and trained staff.
• Improving arrangements for managing stock of medicines and consumables including the safe disposal of out of date vaccines and expired medical consumables.

Establish effective systems to enable the provider to assess and monitor the quality of services and identify, assess and mitigate risks by;

• Implementing formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure there is effective leadership capacity to deliver all improvements.
• Review staffing arrangements and ensure there are enough appropriately qualified staff to meet the needs of patients.
• Ensure staff are supported in their roles and the culture within the practice is improved to encourage staff to report incidents and events.
• Maintain up to date records concerning the management of the regulated activities including;clinical rotas, up to date policies and procedures reflecting current guidance

Ensure systems are in place and operating effectively to keep children safe and safeguarded from abuse including regular liaison with community healthcare professionals.

Ensure all required pre-employment checks are undertaken for staff who require them including checks with the disclosure and barring service (DBS).

The areas where the provider should make improvement are:

• Clarify the appointments process
• Ensure there is a regular programme of staff appraisals in place
• Improve the recording of blank prescriptions within the practice to ensure these can be tracked in line with national guidance.

Due to the nature of the concerns identified on this inspection, urgent enforcement action has been taken to protect the safety and welfare of people using this service. The provider’s registration has been suspended for a period of up to three months.

The clinical commissioning group and NHS have plans in place ensure all risks to patient safety are reviewed.

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

Updated 25 August 2016

The practice is rated as inadequate for providing safe, effective, responsive and well led services; the evidence that led to this rating affects all six population groups.

• There was no evidence to demonstrate that some staff undertaking reviews of patients with long-term conditions such as diabetes had received training and only minimal evidence to show there had been any assessment of their competence in undertaking such reviews. There was no evidence to demonstrate that the aspects of this review which needed to be undertaken by a registered clinician had been completed by the registered clinician.
• Care and treatment for patients did not always reflect current evidence-based practice and this included the care provided for people with long term conditions.
• Performance for diabetes related indicators was 99.9% which was above the clinical commissioning group (CCG) average of 87.3% and the national average of 89.2%. Exception reporting for indicators related to diabetes was 6.7% which was below the CCG average of 10.7% and the national average of 10.8%. However, we were not assured that all information related to the management of long-term conditions was being entered onto the computer system by suitably qualified and registered clinicians.
• However, a search of the practice’s clinical system identified three patients with impaired renal function who were being prescribed metformin which contradicted NICE best practice guidelines. (Metformin

Updated 25 August 2016

The practice is rated as inadequate for providing safe, effective, responsive and well led services; the evidence that led to this rating affects all six population groups.