This practice is rated as requires improvement overall. (Previous rating 01 2018 – Inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Custom House Medical Teaching and Training Practice on 12 September 2018. This inspection was carried under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions and to follow up on breaches of regulations identified during the inspection of 23 January 2018.

At this inspection we found:

• The practice had made significant improvements since our previous inspection and although further improvement remains necessary, the practice is making progress to become compliant with the regulations.
• The practice had taken steps towards stabilisation; there were now four partners and the practice management team better understood their roles and functions.
• Most renovation work excepting the flooring had been completed satisfactorily.
• We found most risks were now being identified, actioned and appropriate steps taken to mitigate harm to patients and other service users.
• Improvements were needed in relation to high-risk medicines and infection control.
• The practice now maintained various matrices to monitor staff training and other important human resources tasks.
• Long term conditions clinical indicators such as QOF remained below CCG and national averages, however unpublished and unverified data demonstrated gains in areas such as diabetes and mental health.
• Patient satisfaction surveys were now in line with local averages, however they remained below national averages; more time was needed to ascertain fully if the initiatives implemented to improve access were working and fully sustainable.
• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• Complaints management was effective, and responses demonstrated adherence to the Duty of Candour.

The areas where the provider must make improvements as they are in breach of regulations are:

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

The areas where the provider should make improvements are:

• Introduce a system to monitor the pharmacist’s work.
• Consider introducing a protocol for sepsis identification and how clinicians record vital signs in patient’s clinical notes.
• Continue to take action to monitor low performing areas such as diabetes, mental health and patient’s satisfaction.

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

This practice is rated as Inadequate overall. (Previous inspection 14 December 2016 – Requires improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Inadequate

Are services responsive? – Inadequate

Are services well-led? – Inadequate

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 – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

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

People whose circumstances may make them vulnerable – Inadequate

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

We carried out an announced comprehensive inspection at Custom House Medical, Teaching and Training Practice on 23 January 2018. We inspected the provider as part of our inspection programme to follow up on areas we found the practice should improve at our previous inspection 14 December 2016.

At this inspection we found:

• The practice had experienced significant changes in staffing , including practice management and a high turnover of GPs.
• Premises improvement works were underway.
• A broad range of clinical and patient satisfaction performance indicators were below local and national averages.
• Risks to patients were not always assessed and well managed including premises, equipment, fire safety and infection control.
• There were gaps in staff training and recruitment checks including safeguarding and references checks for clinical staff.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Information about services and how to complain was available and easy to understand but limited improvement was made to the quality of care in response to concerns.
• The practice did not have effective governance systems to ensure effective management of significant events and safety alerts, but was aware of and complied with the requirements of the duty of candour.

The areas of practice where the provider must make improvements are:

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

• Ensure all premises and equipment used by the service provider are fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Review arrangements for recording clinical audits.
• Review arrangements for responding to patient feedback.

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.

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 Custom House Medical Teaching and Training Practice on 14 December 2016. Overall the practice is rated as requires improvement.

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

• Data showed patient involvement was low compared to the national average. For example, 69% of patients said the last GP they saw was good at involving them in decisions about their care compared to the CCG average of 74% national average of 82%.
• QOF performance for long term conditions was below the national average particularly for diabetes and mental health.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
• Patients said they found it difficult to make an appointment.
• Some patient said they did not find the PPG an open and transparent group and sought representation from a local advocacy group to take their views to the practice.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

• Ensure the proper and safe management of medicines.

• Improve GP patient survey results to ensure better patient satisfaction.

• Improve QOF performance particularly for long term conditions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke to staff including doctors, a nurse, administrative staff and two managers. We spoke to eight people who used the service and collected written feedback from nine people. On the day of our visit we attended the patient participation group meeting.

We found that staff were polite and respected the privacy and dignity of people who used the service. Doors were kept closed during treatment and confidentiality was maintained in the reception area.

Care was assessed and planned to meet individual preferences. One person told us that, “Dr X is very good. He genuinely listens and supports the choices I make relating to my health."

Staff told us that they were supported by their line managers. We found that training was up to date or planned, appraisals were in place. Supervision was structured for trainee doctors however for administrative staff, supervision was not as structured. Staff were up to date with safeguarding training and were able to tell us how they would report any concerns to the named safeguarding lead.

There was an effective system in place to monitor quality of the care provided. We saw that regular feedback was sought from staff and people who used the service. Complaints were reviewed and actioned in a timely manner.