We previously carried out an announced comprehensive inspection on Bath Street Medical Centre on 4 December 2017. Overall the practice was rated as good with requires improvement for providing responsive services. No breach of legal requirement was identified, however we made a number of good practice recommendations. The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Bath Street Medical Centre on our website at .

This inspection was a desk-based review carried out on 19 December 2018 to confirm that the practice had carried out their plan in relation to the issues identified at our previous inspection on 4 December 2017. This report covers our findings in relation to the improvements made since our last inspection.

The practice is now rated as good for providing responsive services and remains rated as good overall.

Our key findings were as follows:

• The practice had implemented an action plan aimed at improving patient response to access.
• In-house surveys carried out by the practice highlighted that improvements in relation to patient access had been made.
• The practice had strengthened their safeguarding procedures; safeguarding policies had been updated to include the most recent definitions of abuse. Discussions held at safeguarding meetings were now documented.
• The practice had strengthened their emergency procedures. They had carried out a risk assessment of staff visibility of the patient waiting area in the event of an emergency situation. A mirror had since been fitted in the waiting room which allowed reception staff to have full visibility of the room.
• A formal induction programme had been introduced for all new staff.
• The practice had achieved a reduction in its prescribing rates for hypnotics (medicines to relieve anxiety, aid sleep, or have a calming effect).
• The uptake rate for cervical screening had improved to 83%.
• A patient recall system had been implemented to invite eligible patients to have the meningitis vaccine.
• A ‘cancer champion’ had been appointed to manage the patient recall system, provide advice on support groups and services and be a point of contact for patients diagnosed with cancer.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bath Street Medical Centre on 26 July 2016. Overall the practice is rated as requires improvement.

We first inspected Bath Street Medical Centre in November 2015 as part of our new comprehensive inspection programme; this inspection however was under the registration of the previous provider. As a result of our inspection, the practice was placed in special measures. Shortly after our inspection, the previous provider had retired from the practice and a salaried GP was appointed as the new principal GP. The principal GP therefore applied for a new registration with the Care Quality Commission.

As a new registered provider, we inspected this service as part of our new comprehensive inspection programme. We carried out a comprehensive inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection was also conducted to see if improvements had been made in line with the special measures period placed of six months, as placed on the previous provider.

Although we found that there were some areas for improvement, our findings indicated that the practice were aware of the areas that required further attention. There was a proactive action plan in place which was being addressed.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. During our inspection we saw that staff treated patients with kindness and respect, and maintained confidentiality.

• Overall figures for medication reviews highlighted areas where improvements had been made due to the practices new recall process. We also saw examples of how the practice had made many improvements to the overall management of their minor surgery service.

• A programme of continuous clinical and internal audit was used to monitor quality and to make improvements.

• Significant events had been discussed with some staff during practice meetings however, we identified that the practice had missed an opportunity to record and reflect on a recent emergency event which was managed effectively in the practice.

• We found that some of the GPs, including the principal GP, were not always able to attend key meetings such as multidisciplinary meetings and also practice meetings where significant events were discussed.

• Although we saw that multi-disciplinary team (MDT) meetings took place on a monthly basis with regular representation from other health and social care services, we found that the meetings were not always well recorded and lacked detail.

• Patients could access appointments and services in a way and at a time that suited them. The practice operated a walk in and wait service every Thursday. This guaranteed that patients could see a GP the same day if attending the surgery before 11:30am. The practice also offered extended hours on Mondays until 8pm.

• Throughout our inspection there was a theme of positive feedback from staff that highlighted how things were improving due to modernisation of processes since the new provider had taken over.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.

• Performance data across some areas was below average, including mental health performance and performance in identifying and screening patients for dementia. Practice performance for cervical screening and smoking cessation highlighted areas for improvement.

The areas where the provider must make improvements are:

• Improve governance of multidisciplinary team meetings to demonstrate that key areas are reviewed and discussions relating to palliative care patients are taking place and are well documented to support this.

• Ensure that GPs are included in key meetings such as practice and multidisciplinary meetings to demonstrate shared learning amongst the team and a structured multidisciplinary approach to patient care.

The areas where the provider should make improvements are:

• Improve overall mental health and dementia performance, ensure that appropriate diagnosis and support packages are in place including care plans and medication reviews.

• Continue to identify carers in order to provide further support where needed.

• Continue to promote health promotional services such as cervical screening uptake and smoking cessation services.

• Continue to engage with patients and work on improving overall medication reviews and ensure that regular reviews are taking place as appropriate.

• Address areas for improvement highlighted through patient feedback such as national survey results.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice