Letter from the Chief Inspector of General Practice

We had previously inspected Five Elms Medical Practice on 5 April 2016, when we had rated the service as inadequate in all key questions and inadequate overall. Following the publication of the inspection report, the practice was placed in special measures for a period of six months. The report from the April 2016 inspection can be found by selecting the ‘Reports’ link for Five Elms Medical Practice on our website at http://www.cqc.org.uk/location/1-569174460.

We carried out a further announced comprehensive inspection on 14 February 2017. We had concerns that the practice had not taken sufficient action to address issues highlighted in the national GP patient survey and had not made suitable arrangements to provide suitable GP cover during periods when either the lead GP, or the long term locum GP was absent from the practice. This meant there remained a rating of inadequate for responsive. Although the overall rating for the service was revised to requires improvement, the practice remained in special measures as it had not made the sufficient improvements to achieve compliance with the regulations. The report from the February 2017 inspection can be found by selecting the ‘Reports’ link for Five Elms Medical Practice at http://www.cqc.org.uk/location/1-2871346124.

This inspection was undertaken following the extended period of special measures and was an announced comprehensive inspection on 10 October 2017. We found that although the practice had brought about improvements to clinical outcomes for patients, it had failed to take sufficient action to address issues highlighted in the national GP patient survey and had failed to ensure that suitable arrangements were in place to provide suitable GP cover over a two week period when the lead GP was absent from the practice. Overall the practice is still rated as requires improvement.

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Our key findings were as follows:

• Patient satisfaction levels were still significantly below local and national averages. Comment cards received and the views of patients we spoke with on the day aligned with these findings.
• The practice had not made effective arrangements to cover a period when the lead GP was absent which meant that patients continued to experience difficulties accessing GP appointments..
• There was a leadership structure in place but there was lack of clarity about authority to make decisions.
• Processes to monitor prescriptions awaiting collection were not always being followed.
• The practice had recently engaged with the Royal College of General Practitioners’ ‘Peer Support Programme’ for practices placed in Special Measures. This provided access to expert professional advice, support and peer mentoring from experienced, senior GPs, practice managers and nurse practitioners with specialist expertise in quality improvement.
• Quality Outcomes Framework (QOF) data for 2016/2017 showed that outcomes for patients with long term health conditions had improved and were now in line with local and national averages. Exception reporting rates had been reduced for all clinical indicators and were now comparable to or lower than CCG and national averages. (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).
• Evidence showed that patient safety alerts were being received and acted upon.
• The practice had carried out two competed cycle audits to drive improvement in patient outcomes.

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

Importantly, the provider must:

• Continue to seek and act on feedback from patients on the services provided, for the purposes of continually evaluating and improving such services.
• Take action to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are available to meet patient needs.

In addition the provider should:

• Consider including contact details for all members of staff in the business continuity plan so that staff can be easily contacted in an emergency.
• Consider arrangements in place to support patients who wish to see a female GP.
• Continue to review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

This service was placed in special measures in August 2016 and this arrangement was extended for a further six months in May 2017. Insufficient improvements have been made such that there remains a rating of inadequate for responsive and an overall rating of requires improvement. Therefore we are taking 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 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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Five Elms Medical Practice on 5 April 2016. The practice was rated inadequate for safe, effective, caring, responsive and well led. The practice was given an overall inadequate rating and placed in special measures The full comprehensive report on the 20 April 2016 inspection can be found by selecting the 'all reports' link for Five Elms Medical Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 14 February 2017. Overall the practice is rated as requires improvement.

Our key findings were as follows:

• Levels of patient satisfaction around access to the service and involvement in planning and making decisions about care and treatment were still significantly below local and national averages although there were improvements in all areas compared to the April 2016 inspection.
• The practice had been unable to make effective arrangements in place to cover periods of GP absence although there was evidence of actions taken to mitigate the impact of lost GP sessions.
• Although data from the Quality Outcomes Framework showed patient outcomes were generally comparable to the national average, there were areas where performance was significantly below the national average, including those for patients diagnosed with dementia.
• At our last inspection in April 2016 we found that the practice had not undertaken any completed clinical audit cycles and there was no clear audit strategy in place. At this inspection we found that the practice had developed an audit plan for 2016/17 and had undertaken four clinical audits, including one completed audit.
• The practice had recently begun to promote online access to services.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• The practice had good facilities and was well equipped to treat patients and meet their needs
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
• There was a clear leadership structure and staff said they felt increasingly supported by management. The practice had begun to seek feedback from staff and patients but processes had not been fully established.
• The provider was aware of and complied with the requirements of the duty of candour.

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

Importantly, the provider must:

• Continue to seek and act on feedback from patients on the services provided, for the purposes of continually evaluating and improving such services, including improving access to the practice and patient satisfaction around involvement in planning and making decisions about care and treatment.
• Take action to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are available to meet patient needs.

In addition the provider should:

• Ensure the practice business continuity plan is available to staff, including whilst off-site.
• Continue to monitor Quality Outcomes Framework performance to improve performance in relation to the management of long-term conditions and ensure exception reporting rates are closely scrutinized.
• Consider further ways of promoting online access to services, including a review of the practice website and leaflet.
• Continue to review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Review arrangements to support patients with impaired hearing.

This service was placed in special measures in August 2016. Insufficient improvements have been made such that there remains a rating of inadequate for providing responsive services. 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 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice