We carried out an announced focused inspection at Fitzalan Medical Group on 21 November 2018.

At this inspection we followed up on breaches of regulations identified at our previous inspection in August 2018. The ratings remain unchanged from the August 2018 inspection as the purpose of this inspection was to review compliance against the warning notices issued.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

At this inspection we found, the practice had made significant improvements and was compliant with the warning notices, in particular:

• A system was in place for monitoring the prescribing of controlled drugs and medicines that can be subject to abuse.
• The practice had properly assessed the effectiveness and appropriateness of the care it provided for patients with long term conditions, including areas where exception reporting was high. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).
• Realistic plans were in place to complete outstanding annual health check and medicines reviews. Performance against these plans was monitored regularly.
• The practice had cleared the backlog of correspondence and put in place systems to minimise the risk of backlogs occurring in the future.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

This practice is rated as inadequate overall. (Rated December 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

We carried out an announced focused inspection at Fitzalan Medical Group on 11 June 2018, to follow up on breaches of regulations identified at our inspection in February 2018. The ratings remain unchanged from the December 2017 inspection as the purpose of the February, April and June inspections were to review compliance against the warning notices issued. Due to concerns raised about the practice this inspection was expanded to review the acute and repeat prescribing processes.

When we undertook a follow up inspection of the service on 1 February 2018 we found that the arrangements in safe had not improved sufficiently and we issued a warning notice in respect of these issues. The details of these can be found by selecting the ‘all reports’ link for Fitzalan Medical Group on our website at www.cqc.org.uk.

At this inspection we found:

• The practice had addressed the concerns that were identified at our previous inspections and was compliant with the requirements of the warning notice.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

However, there were also areas of practice where the provider needs to make improvements.

• There was some improvement to the review of significant events and action taken as a result, however, this was not consistent. There was no system to ensure that an overview of trends and themes was maintained so it was not clear that trends and themes would be identified.
• Water temperature checks were outside of the range recommended within the legionella risk assessment and policy. This had not been identified by the practice; therefore action to address it had not been taken.

Importantly, the provider must:

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fitzalan Medical Group on 19 December 2017. The overall rating for the practice was inadequate. The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Fitzalan Medical Group on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1 February 2018 to confirm that the practice was compliant with a warning notice issued following the December 2017 inspection. A warning notice was issued against regulation 12 (1) (safe care and treatment) and of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report covers our findings in relation to the requirements against regulation 12 (1) (safe care and treatment).

The ratings remain unchanged from the December 2017 inspection as the purpose of the February 2018 inspection was to review compliance against the warning notice issued.

Our key findings were as follows:

• Systems for managing medicines had improved, including improvements to the safety of repeat prescribing practices.
• Medicines prescribed to patients were being regularly reviewed to support treatment, optimise their impact and improve safety.
• The practice had improved the monitoring processes to ensure that blood tests had been carried out prior to the prescription of high risk medicines.
• The practice had made improvements to the tracking of blank prescriptions and the safe storage of medicines. Patient group directions (PGDs) were appropriately authorised.
• Patient medicine and safety alerts were acted on, and the actions taken were recorded.
• There was improved monitoring of emergency medicines and a broader range of emergency medicines were available to address the types of emergencies the practice may face.
• There was improved monitoring of the vaccine fridges. Training for staff on this process had also been undertaken.
• There were improved checks and follow up for patients following abnormal blood results or action required from correspondence received.
• There was a clear infection control action plan that included risk assessments and timescales for action.

However, there were also areas of practice where the provider needs to make improvements.

• Patients on blood thinning medicines did not always have their blood test results reviewed prior to repeat medicines being prescribed.

Importantly, the provider must:

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

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 June 2015 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

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 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 Fitzalan Medical Group on 19 December 2017. The inspection was in response to concerns raised following a notification from the coroner about prescribing, monitoring and review processes within the practice.

At this inspection we found:

• Safety risk assessments had either not been undertaken or had not been reviewed. Risks were not consistently or adequately mitigated.
• Systems for managing medicines were unsafe, including inadequate repeat prescribing processes and poor monitoring and review of patients on high risk or repeat medicines.
• Medicines were not always stored securely and monitoring of the vaccine cold chain was insufficient. Blank prescriptions were not tracked within the practice. Patient Group Directions (PGDs) did not include the name of the practice recorded on them.
• There was no risk assessment in place for the types of emergency medicines needed within the practice. Monitoring of emergency medicines and equipment was inconsistently recorded.
• There was no formal system to ensure that abnormal test results and correspondence were acted on.
• There was no system to ensure or record action from safety alerts.
• There was little evidence of learning or changes to practice as a result of significant events.
• There was insufficient action planned or taken as a result of routine infection control audits.
• Quality Outcomes Framework (QOF) data showed the practice was performing significantly below national standards in a number of areas including dementia, mental health and chronic obstructive pulmonary disease. Patients with long-term conditions did not always have a structured annual review, however there was some evidence during inspection that these areas were beginning to be addressed.
• The practice performed above target for three out of the four childhood vaccines up to age two, however fell below standard for the pneumonia booster for two year olds.
• There were some gaps in staff training and the practice had not routinely ensured the ongoing competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
• Results were below local and national averages for two out of four of the questions in the GP patient survey relating to patients feeling involved in decision making about their care.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had been addressing issues relating to access to services by increasing the availability of appointments and had recruited three additional GPs and three paramedic practitioners in the last year.
• Leaders did not evidence that they had the skills and capacity to address risks and deliver high quality sustainable care.
• Structures, processes and systems to support good governance and management were ineffective in relation to the management of safety, risk and quality improvement.
• There was no system to ensure the regular review of practice policies and in some cases practice activity was not undertaken in line with the policies.
• There were inconsistent processes to identify, understand, monitor and address current and future risks including risks to patient safety.
• There was no comprehensive audit plan for the practice and no evidence of current auditing of clinical performance.
• Learning was not consistently shared and used to make improvements.

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.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The areas where the provider should make improvements are:

• Take action to improve performance against the standard in relation to childhood vaccines.
• Take action to improve how clinical staff involve patients in decisions about their care in response to GP patient survey results.

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 of this practice on 13 January 2015. Breaches of legal requirements were found in relation to the safe management of medicines. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements. We undertook this focused inspection on 19 November 2015 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

Our previous report also highlighted areas where the practice should improve:-

• Ensure the chaperone policy is visible on the waiting room notice board and in the consulting rooms.

• Provide patients with greater flexibility for making appointments.

• Take action to address identified concerns with infection prevention and control practice.

• Provide an opportunity for all practice staff to meet on a regular basis.

• Ensure all staff are familiar with the practice’s whistleblowing procedure and that it is included in the staff handbook.

• Provide an opportunity for the virtual patient representative group (VPRG) to meet with the practice on a more regular basis.

Our key findings across the areas we inspected for this focused inspection were as follows:-

• The nurses and the health care assistants were now administering vaccines using directions that had been produced in line with legal requirements and national guidance.

• The chaperone policy was now visibly displayed on the walls of each consulting room.

• The practice had reviewed its appointment system and was in the process of implementing changes that would allow patients more flexibility in making appointments.

• The practice had held meetings which allowed all practice staff to attend. These now took place every six months.

• The practice had addressed concerns identified in relation to infection control. For example, all bins were now pedal operated.

• All staff were familiar with practice’s whistleblowing policy which was now included in the employee handbook.

• Arrangements had been put in place to ensure that the VPRG had the opportunity to meet with the practice on a more regular basis.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fitzalan Medical Group on 13 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing, effective, caring, responsive and well led services. However the practice is rated as requires improvement for providing safe services. The practice was also rated as good for providing services to the six population groups.

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

• The practice had a system in place for reporting, recording and monitoring significant events, incidents and accidents. There was evidence that the practice had learned from these and that the findings were shared with relevant staff.
• Patient feedback was positive. Patients said they were treated with compassion, dignity and respect. They said they felt listened to and that they were involved in decisions about their care and treatment.
• The practice had implemented innovative approaches to providing care. For example, by employing a paramedic practitioner.
• The practice responded positively to the needs of its patients. For example by employing staff who could speak Polish, Russian and Lithuanian to meet the needs of the patients from Eastern Europe on its register.
• Staff felt well supported in their roles and had good access to training.
• The practice had an active virtual patient reference group (VPRG).

There were also areas of practice where the provider needs to make improvements.

Specifically the provider must:-

• Ensure all nursing staff implement patient group and patient specific directives in line with national guidance.

In addition, the provider should:-

• Ensure the chaperone policy is visible on the waiting room noticeboard and in the consulting rooms.
• Provide patients with greater flexibility for making appointments.
• Take action to address identified concerns with infection prevention and control practice.
• Provide an opportunity for all practice staff to meet on a regular basis.
• Ensure all staff are familiar with the practice’s whistleblowing procedure and that it is included in the staff handbook.
• Provide an opportunity for the VPRG to meet with the practice on a more regular basis.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We inspected Fitzalan Medical Group to look at the care and treatment provided by staff to the patients. We spoke with five patients during our visit as well as five members of staff (which included the practice manager and the registered manager). We also collected six responses to a questionnaire that we left in the waiting area for patients.

We observed during our visit that staff treated patients with respect. We noted that reception staff greeted and spoke politely to patients. One patient told us that they felt respected by the staff at the practice “All the time.”

We found that the practice had good relationships with other providers and healthcare professionals. Patients who had been referred outside of the practice told us that the process had been smooth and efficient. One patient we spoke with said “I have regular hospital visits and the communication is very good between the practice and the hospital.”

We found that staff were aware of procedures around safeguarding vulnerable adults and children. We saw that the practice had relevant safeguarding policies and guidance and there were two safeguarding leads at the practice.

We found the practice hygienic and clean. The practice had good systems in place which ensured that patients were not at risk of infection.

The practice had a complaints procedure which was made available to patients. None of the patients we spoke or who completed our questionnaire with had ever felt the need to make a complaint.

This practice is rated as

inadequate overall. (Previous rating December 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Fitzalan Medical Group on the 7 and 8 August 2018. This was to follow up on breaches of regulations and as part of our schedule of inspection where services placed in special measures will be inspected again within six months.

At this inspection we found:

• There was recognition by the providers of the improvement required however the necessary improvement had not been made.
• The practice were working very hard and new processes were being put in place. However, systems for implementation to actually deliver improvement in a co-ordinated way were lacking.
• There were significant concerns around the culture and leadership.
• Patients with long-term conditions did not always have a structured annual review. Quality Outcomes Framework (QOF) data showed the practice was performing significantly below national standards in a number of areas including, asthma, mental health and chronic obstructive pulmonary disease.
• Structures, processes and systems to support good governance and management were ineffective in relation to the management of safety, risk and quality improvement.
• There were inconsistent processes to identify, understand, monitor and address current and future risks including risks to patient safety.
• The practice had introduced a new protocol for when children did not attend appointments. A code was added to the clinical record which was distinct from the standard “did not attend” code enabling the practice to differentiate between adults not attending appointments and children not being brought to appointment. This protocol enabled the practice to identify two children who required safeguarding referrals.

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

This service was placed in special measures in March 2018. Insufficient improvements have been made such that there remains a rating of inadequate overall and for providing safe, effective and well-led services. Therefore, we are taking action in line with our enforcement procedures. 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice