We carried out an announced comprehensive inspection at Dogsthorpe Medical Practice on 21 February 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection in July 2018

This is the third inspection for Dogsthorpe Medical Centre under the current provider McLaren Perry Limited. The practice had been inspected previously under the provider First Health (Peterborough) Limited in May 2015, June 2016 and November 2016. At our June 2016 inspection the practice was rated as inadequate and placed into special measures. At our inspection in November 2016, the improvements required had not been made and the practice was rated as inadequate with the CQC registration of the provider First Health (Peterborough) Limited suspended.

On our first inspection under the current provider McLaren Perry Limited on 4 December 2017, improvements had been made and the practice was rated as requires improvement. At our second inspection in July 2018, we found the provider had not continued to make sufficient improvement in response to the breaches of regulation identified and the service was rated inadequate overall and remained in special measures.

We have rated this practice as requires improvement overall.

We rated the practice as good for providing safe services because sufficient improvements had been made since our last inspection, including:

• Protocols and procedures for the safe and secure storage of medicines were reviewed implemented and monitored. Medicines stored in the refrigerator were safe to use and regularly checked.
• The provider had good oversight of risks including regular review and ensured action was taken to address issues and make improvements.
• Significant events were well documented and we saw evidence demonstrating learning had been shared, however the practice should consider how information shared in daily huddle meetings is recorded.
• The system for managing patient, medicines and device safety alerts had been reviewed, improved and was monitored to ensure patients were kept safe.

We rated the population groups people with long term conditions, working age people (including those recently retired and students), people experiencing poor mental health and the practice overall as r

equires improvement for providing effective services because:

• Since our last inspection, the practice had appointed a member of staff as quality and outcomes framework performance lead, supported by lead clinicians, responsible for improving performance, monitoring patient registers and introducing recall systems to ensure that patients received appropriate and timely care. The practice shared with us unverified performance data for 2018/19 which demonstrated improved performance compared with previous years and that there were plans in place to continue to improve. However, some areas remained below local and national averages including indicators for mental health care patient reviews, indicators of well controlled diabetes and uptake for national cancer screening programmes.

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

• Data from the latest national GP patient survey was below local and national averages. The provider had conducted their own patient survey which demonstrated overall satisfaction was improving, however the provider survey had focussed on access to appointments and had not covered all the below average areas relating to caring services.
• However, since our last inspection, the practice had reviewed and improved their complaints process and set aside allotted time each week for patients to book to speak with the practice manager directly, as well as being able to make a complaint in writing or verbally. We saw that complaints were appropriately recorded and dealt with in a timely manner.

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

• Patient satisfaction levels in relation to accessing the practice were below CCG and England averages in all indicators in the GP National Patient Survey. The practice shared with us a patient survey undertaken to evaluate the changes made following negative patient feedback. This patient survey evidenced improvements in patient satisfaction but was not entirely comparable to the GP National Patient Survey; therefore, it was not possible to conclusively determine patient satisfaction levels had improved.

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

• The provider had continued to make, and were able to demonstrate, improvements in the service since our last inspection; however further improvements were still required in relation to the quality of care provided to patients and improving patient outcomes and satisfaction.
• Governance systems had strengthened and ensured that the quality and safety of services provided was managed effectively.
• The practice had improved management oversight of systems to manage risk, including fire safety and infection prevention and control.
• The practice had implemented and reviewed new systems to ensure the safety and appropriate storage of medicines.
• The provider had employed a clinical pharmacist to help manage medicines and prescribing in the practice. We found systems and processes to ensure patients receiving repeat medicines were well managed. The service had improved the way high risk medicines were managed and we found these patients were appropriately monitored.
• Results from the most recent national GP patient Survey were generally below, and in some areas significantly below, local and national averages. The practice had made changes to drive improvements in patient satisfaction and had conducted their own patient survey which demonstrated patient satisfaction had improved, however further improvement was required.

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

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Introduce a formal practice policy for reception staff signposting patients to appropriate care pathways.
• Improve how information systems to manage risks record information shared in daily ‘huddle’ meetings.
• Review the systems for managing patient safety alerts to ensure reviews of alerts where no action is required are recorded.

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

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

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement. This is the first inspection for Dogsthorpe Medical Centre under the current provider McLaren Perry Limited. The practice had been inspected three times previously under the provider First Health (Peterborough) Limited in May 2015, June 2016 and November 2016. At our June 2016 inspection the practice was rated as inadequate and placed into special measures. At our inspection in September 2016, the improvements required had not been made and the practice was rated as inadequate and the CQC registration of the provider First Health (Peterborough) was suspended.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people Requires Improvement

Working age people (including those retired and students - Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement

We carried out an announced comprehensive inspection at Dogsthorpe Medical Centre on 4 December 2017. This inspection was undertaken following the period of special measures. Overall, the practice is now rated as requires improvement. The practice is no longer in special measures.

At this inspection we found:

• The provider McLaren Perry Limited took over the management of the practice in September 2016; the practice team had developed an action plan and had made significant improvements to the safety and culture within the practice. The management team from McLaren Perry, consisting of a GP medical director and a GP clinical lead and practice manager, had involved the practice staff and made changes to encourage improvement.
• Practice staff we spoke with told us they were proud of the improvements the practice had made and that they enjoyed working in the practice, but understood that further improvements were required and had a plan to address this.
• The practice had reviewed the needs of their local population and changes made reflected the diverse cultural groups.
• A significant number of staff had left the practice; the management team had reviewed the skill mix and recruited new team members.
• The practice performance in relation to the quality and outcome framework 2016/2017 was significantly low when compared to the local clinical commissioning group (CCG) and national averages. The practice was aware of this and shared their performance data for 2017/2018 (unverified) and their plans to improve this.
• 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.
• Results from the national patient GP Survey published in July 2017 were generally below and in some areas significantly below the CCG and national averages. The practice had made changes to drive improvements to patient satisfaction. Patient feedback was gathered at every opportunity including that of children and young people.
• There were policies and procedures in place and but these needed improvement. Not all were practice specific and some staff were not able to access them easily.
• We saw evidence that patients and members of the PPG were supportive of the changes made and they had reported better patient experiences.
• Staff involved and treated patients with compassion, kindness, dignity, and respect.
• Some patients found it difficult to use the appointment system and reported that they experienced difficulties in obtaining pre booked appointments with the GP of their choice. The practice had reviewed the appointment system and had made changes.
• There was innovation and service development and improvement was a priority among staff and leaders.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure the plan to drive improvement through clinical audit is embedded and changes monitored to sustain improvement.

The areas where the provider should make improvements are:

• Continue to monitor the National Patient Survey data and continue to make changes to improve the experience of patients.
• Continue to develop systems and processes to identify carers to ensure they receive appropriate support.

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

This practice is rated as Inadequate overall.

This is the second inspection for Dogsthorpe Medical Centre under the current provider McLaren Perry Limited. The practice had been inspected previously under the provider First Health (Peterborough) Limited in May 2015, June 2016 and November 2016. At our June 2016 inspection the practice was rated as inadequate and placed into special measures. At our inspection in November 2016, the improvements required had not been made and the practice was rated as inadequate and the CQC registration of the provider First Health (Peterborough) was suspended.

On our first inspection under the current provider McLaren Perry Limited on 4 December 2017 improvements had been seen and the practice was rated as requires improvement and removed from special measures.

The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Dogsthorpe Medical Practice on our website at www.cqc.org.uk.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Dogsthorpe Medical Practice on 10 July 2018 to follow up on breaches of regulations identified in our inspection 4 December 2017.

At this inspection

• We found there was a lack of leadership and we were not assured that the systems and processes in place at the practice would keep patients and staff safe from harm.
• We found that the practice had not sustained improvements made and had not made further improvements to address the concerns identified in our inspection in December 2017 to ensure that patients were monitored effectively and kept safe from harm.
• Governance systems did not ensure that the quality and safety of services provided was managed effectively.
• The practice did not have clear management oversight to ensure systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not always evidence that they had shared the learning and improved their processes.
• There was a lack of oversight to ensure that the systems and processes in place to mitigate risks to patients such as fire safety and infection prevention and control were reviewed and monitored appropriately. We found out of date medicines in a refrigerator that was used to store medicines and there was no system in place to check the medicines stored in the refrigerator were safe to use.
• Generally, we found the systems and processes to ensure patients receiving repeat medicines were well managed. However, we found some patients on high risk medicines had not been reviewed appropriately.
• The practice did not evidence that the recall systems in place were effective in ensuring that patients received appropriate and timely care. The practice shared with us the new system of registers they had implemented to monitor and improve their performance.
• The practice shared data from the quality and outcome framework for 2017/2018. They had failed to make planned improvements on the low performance reported in our inspection in December 2017. However, the practice told us that they had reviewed all the patients who maybe experiencing poor mental health. We saw examples of comprehensive care plans for these patients. The practice had also reviewed all their patients who may have a learning disability and those with dementia.
• The practice did not evidence a consistent approach to complaints and feedback to ensure they were all recorded ensuring all learning was shared and changes monitored.
• Results from the national GP patient Survey published in July 2017 were generally below, and in some areas significantly below, the national averages. The practice had made changes to drive improvements in patient satisfaction but did not provide any evidence that showed if patient satisfaction had improved as a result.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• To help and support patients who maybe experiencing poor mental health or those who felt isolated the practice had with Insight health started a time to talk session. A knit and natter group was due to start in August 2018.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that safe care and treatment is provided in a safe way for service users.

The areas where the provider should make improvements are:

• Continue to monitor the National Patient Survey data and continue to make changes to improve the experience of patients.

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