We carried out an unannounced focused inspection at Dr Jones SR Practice / Rigg Milner Medical Centre on 19 March 2019. At this inspection, we followed up on whether the provider had complied with our warning notice, served following an announced comprehensive inspection at Dr Jones SR Practice / Rigg Milner Medical Practice on 30 October 2018. We were also responding to concerns that had been raised about the service.

During our inspection on 30 October 2018, we found that the service was not carrying out safe, effective or well-led care. Breaches of regulation were identified. We served a warning notice in respect of safety at the practice. This was because: staff files did not evidence whether appropriate recruitment checks had been completed; recommendations from a risk assessment hadn’t been completed and other risk assessments either weren’t completed or weren’t completed correctly, monitoring checks and tests for, fire alarm, defibrillator, calibration and portable appliances were not being completed; the vaccine refrigerator was overfull.

During our focused inspection on 19 March 2019, we found that improvements had been made and the provider had met most of the requirements of the warning notice. However, there were still breaches of regulation and further breaches were identified.

At this inspection we found:

• While the practice had made some improvements since our inspection on 30 October 2018, it had not completely addressed the Warning Notice in relation to the recruitment processes and Legionella monitoring.
• There were appropriate monitoring checks on emergency equipment.
• An external company had been booked to provide infection control training and to complete an infection control audit.
• There was a fire procedure that included up to date details of fire marshals. There were weekly fire alarm checks.
• Portable appliance testing and calibration of medical equipment had been completed.
• A premises risk assessment had been completed.
• Reception staff were routinely directing patients to the local walk in centre or A&E as they did not have clinical capacity to treat those patients.
• A monitoring system for prescription stationery had been set up. Prescription security still required further strengthening.
• Although documents containing information about the care and treatment required for patients had been scanned to the electronic system, they had not been matched to the patient record, putting some patients at risk.
• Leaders did not have the capacity to effectively manage the governance of the practice. Patients were put at risk due to this.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

The areas where the provider should make improvements are:

• Implement a coherent system to evidence staff vaccination checks.
• Continue to strengthen processes relating to blank prescription security.
• Review clinical staffing to ensure that there is sufficient capacity to meet patient demand.
• Review governance structure to support effective systems and processes.

Although some further improvements were required, we were satisfied that the practice had made sufficient progress in relation to the Warning Notice. The practice will receive a further comprehensive inspection in the next few months where we will be checking progress against the outstanding matters and re-rating the practice.

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

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Inadequate

We carried out an announced inspection at Dr Jones SR Practice / Rigg Milner Medical Practice on 30 October 2018 as part of our inspection programme.

At this inspection 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.
• There was insufficient evidence that the practice carried out appropriate staff checks at the time of recruitment. Although, there was clear evidence that checks on clinicians’ status on the performers’ list were completed on an ongoing basis.
• The provider had not acted on recommendations from a Legionella risk assessment.
• Fire alarm testing was not being completed and the fire procedure had not been updated.
• Although infection control checks were being completed, staff lacked understanding of what the checks were asking therefore some the completed checks had incorrect responses.
• All staff were aware of actions to take in emergency situations affecting patients or business continuity.
• The systems in place for managing repeat prescriptions and test results were safe.
• Prescription stationery was not kept securely or monitored. The vaccine refrigerator was overpacked.
• Systems relating to emergency medicines and equipment required strengthening. There were no checks on the emergency equipment, or expiry dates of medicines. Full consideration had not been given to which emergency medicines the practice required.
• 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.
• There was evidence of improvement in the care of patients with diabetes.
• Further work was required to ensure that patients with a diagnosis of depression were receiving appropriate review.
• Feedback from comments cards about the care received and attitude of staff were positive.
• Feedback received from patients, we spoke on the day, was mixed.
• Patients views on access to the service were mixed.
• Due to ongoing contractual issues, at the time of our inspection, the practice was unable to offer extended hours appointments at the practice, however could access weekend and evening appointments through the local hub. They also no longer offered online appointment booking.
• Complaints were not handled in a timely manner and they did not follow the practice policy.
• The practice had had a high turnover of staff and had a new staffing structure in place. Staff comments regarding the current staff structure were positive.
• The practice had a strong patient participation group (PPG). However, the practice leaders had not prioritised their concerns so the PPG felt ineffectual.
• There was a lack of leadership and governance at the practice which included identifying and acting on risk.

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.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Implement a system to identify patients who are carers and provide them with appropriate support.
• Review access to the practice by telephone and patients overall experience of the appointment system.

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 FRCGPChief Inspector of General Practice