26 April 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
The Practice Hangleton Manor was inspected in September 2015 where they were rated inadequate in safe, effective, caring and well-led services. They were rated as good in responsive. As a result the practice was placed into special measures and a warning notice was issued. In February 2016 we carried out a focussed inspection of the areas covered by the warning notice and found that this had not been met. The warning notice was re-issued and was subject to written representations at the time of the announced comprehensive inspection at The Practice Hangleton Manor on 26 April 2016. Overall the practice is rated as inadequate.
Our key findings across all the areas we inspected were as follows:
- The practice was going through a period of uncertainty due to giving notice on their NHS England contract and this had resulted in some staff resigning from their posts at a time when the practice was experiencing difficulties with recruitment.
- There was no clear vision, strategy or business plan. However, The Practice Group/Chilvers and McCrea had developed an exit plan for the end of June following NHS England being given contractual notice. The practice were increasingly dependent on locum staff who were not given additional time to undertake activities such as care planning and attendance at practice meetings, despite taking a clinical lead on a day to day basis.
- The governance systems within the practice did not cover all aspects of clinical activity and not all risks had been properly evaluated and mitigated. For example, monitoring of blood results was undertaken remotely by the lead locum but there were no formal arrangements in place for this and there was no central system evident for how the practice should deal with national guidance and safety alerts.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, locum staff did not have access to the reporting system and were not always involved in discussions and learning from incidents.
- Risks to patients were assessed and well managed, with the exception of those relating to medicines management.
- Published data showed patient outcomes were low compared to the national average, although we saw that the practice had worked to improve these for 2015/16.
- Patients with conditions such as dementia and those with a learning disability were not routinely receiving annual reviews..
- The practice had worked hard to set up multi-disciplinary meetings for patients at the end of life and those who were vulnerable. However, this had not yet happened and alternative ways to meet other than face to face had not been realised.
- Clinical audits had been carried out, including evidence of a full cycle audit being used to drive improvements to patient outcomes.
- The majority of patients said they were treated with compassion, dignity and respect. However, results from the GP patient survey were low in comparison to local and national figures. For example, in relation to explaining tests and treatments and involvement in care planning.
- The practice demonstrated some good work around the support they offered for carers and had carried out audits of this to ensure they were meeting carer’s needs.
- We saw evidence of improved processes around the handling of complaints and acting on feedback from patients. For example, by using audit as a tool to monitor and ensure improvements.
- The practice had significantly changed their appointment system to increase the number of face to face appointments. This had been a concern identified in previous inspections and through negative patient feedback around the previous telephone triage system.
The areas where the provider must make improvements are:
- Monitor and assess risks associated with the current staffing issues to ensure that increased risks are adequately mitigated regarding support for locum staff to ensure that safety is not compromised in relation to limited clinical leadership within the practice.
- Ensure that there is a central system for dissemination of national guidance and safety alerts that provides assurance that this guidance and alerts are being adhered to.
- Ensure that there is a formal system for monitoring of test results and clinical correspondence that is not dependant on an individual locum GP.
- Ensure that privacy and confidentiality are maintained in relation to the handling of telephone calls and patient information at the reception desk.
- Ensure that temperature monitoring of the vaccination fridge is carried out in line with national guidance and the practice policy, that patient group directions are signed by all locum nurses administering them and that competency has been assessed and that prescriptions are securely locked away and adequately tracked within the practice.
- Ensure that emergency medicines and oxygen with appropriate masks are easily accessible to all staff and that there is a system in place to monitor this during a time when the practice is dependent on locum staff.
- Ensure that all patients requiring regular reviews of their health have these available to them, that all patients on a chronic disease register have a care plan in place and that regular multi-disciplinary meetings are held for patients at the end of life and for those who are vulnerable.
- Ensure that information from the national GP patient survey is acted on and used to improve practice and that alongside improvements in care planning patients are involved in planning their care.
- Ensure that the risks associated with the uncertain future of the practice are fully identified, assessed and mitigated and that close monitoring and reporting to the appropriate external bodies is undertaken.
This service was placed in special measures in December 2015. Insufficient improvements have been made and there remains a rating of inadequate for all the population groups, two key questions and overall. Therefore, the practice continues to be in special measures. On 15 July 2016 this practice was closed by the provider.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice