This practice is rated as Good overall. (Previous rating 07 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at LL Medical Care Limited on 23 May 2017 as a part of our inspection programme. The overall rating for the practice was requires improvement as there were breaches in the proper and safe management of medicines, assessing the risk for electrical equipment used and recruitment processes. There were also concerns with infection control, identifying patient carers, staff training, patient satisfaction, patient clinical outcomes and business continuity arrangements. The full comprehensive report published in July 2017 can be found by selecting the ‘all reports’ link for LL Medical Care Ltd on our website at .

This inspection was an announced comprehensive inspection on 19 July 2018, carried out to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified in our previous inspection on 23 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• 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.
• The practice had an effective system for monitoring high risk medicines and positive test results.
• 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.
• Documentation in patients’ records were detailed and effective.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Adequate infection and prevention control procedures were in place.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• The practice proactively identified carers and over 1% of the practice list was coded as having caring responsibilities.
• Complaints were managed in an appropriate and timely manner, but the practice could not demonstrate that learning was shared in a timely way.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Ensure learning and outcomes from complaints are shared with all relevant staff member in a timely way.
• Continue to work to improve patient satisfaction as identifies from the national GP patient survey.

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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at LL Medical Care Ltd on 19 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report published in November 2016 can be found by selecting the ‘all reports’ link for LL Medical Care Ltd on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 23 May 2017, carried out to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 19 April 2016. There were breaches in the proper and safe management of medicines, assessing the risk for electrical equipment used and recruitment processes. There were also concerns with infection control, identifying patient carers, staff training, patient satisfaction, patient clinical outcomes and business continuity arrangements. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events and sharing the learning and outcomes of these.

• The practice did not adequately monitor patients on high risk medicines before issuing prescriptions.
• The practice achieved low GP patient satisfaction scores in several aspects of care.
• Systems for actioning positive tests results were not consistently effective and timely.
• Documentation in patients’ records were not always detailed and effective.
• Data from the Quality and Outcomes Framework showed patient outcomes were mostly comparable to the local and national averages and overall exception reporting was lower than the CCG and national averages.
• The practice held extended hours appointments on two weekday evenings per week and telephone consultations and online appointment bookings were available daily.
• There were processes in place to register patients with no fixed address.
• The practice did not have access to certain cleaning materials when health centre staff were not on the premises and not all reception staff members were unaware of the use of a spillage kit.
• Childhood immunisation rates were below the national standards.
• All staff within the practice had a sound knowledge about bot adult and child safeguarding and were trained to the levels sufficient for their role.
• There was evidence of quality improvement including clinical audit.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. This included feedback from the active patient participation group.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

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

Importantly, the provider must:

• Embed systems to ensure that positive test results are reviewed and actioned in a timely way.
• Ensure the new practice system for monitoring and managing patients on high risk medicines are embedded in practice.
• Consider documentation processes to ensure that all necessary information is captured in patient notes.

In addition the provider should:

• Review the system for identifying patient carers to ensure appropriate support is provided to them.
• Ensure all staff members are trained in the use of a spillage kit and consider how to gain access to all the required cleaning materials throughout the day.
• Consider arrangements for patients who are hard of hearing.
• Review recruitment arrangements to ensure that all the necessary documentation such as indemnity insurance is in place before clinical staff members are employed.
• Review systems to monitor and improve clinical outcomes, including childhood immunisation rates.
• Continue to look at ways to improve patient satisfaction with services including access to appointments and getting through to the practice by telephone.

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 LL Medical Care Limited on 19 April 2016. Overall the practice is rated as requires improvement.

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

• Arrangements for managing and storing Controlled Drugs did not conform to regulations (Misuse of Drugs Regulations (2001)). The practice did not keep a Controlled Drugs register and stocks of these medicines were stored in a cabinet which was easily removable. The practice took steps to resolve this immediately after this was pointed out to them.
• There were concerns about the way the fridge used for storing vaccines was being managed. The fridge was stocked in a way which did not allow for sufficient space around the vaccine packages for air to circulate and some vaccine packages were touching the walls of the fridge. Although recorded temperatures were within an acceptable range, there was a risk of individual doses freezing and this could render certain vaccines ineffective.
• Pre-employment checks had not been undertaken for all staff. For instance, proof of identification and copies of references were not available for six employees. including two members of staff recruited within the past three years.
• The practice did not have a process to ensure that carers were identified and recorded on the clinical system and had identified significantly less than 1% of their patients as also being carers.
• Risks to patients were assessed and managed, with the exception of those relating to staff recruitment checks.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• The majority of patients said they were treated with compassion, dignity and respect.
• Information about services was available and the practice website was accessible in a range of community languages as well as in a format which was more accessible to patients with dyslexia.
• The practice had a number of policies and procedures to govern activity.

The areas where the provider must make improvements are:

• Ensure all portable electrical appliances are safe to use.
• Ensure that recruitment arrangements include all necessary pre-employment checks for all staff and that the information required by schedule 3 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is kept on staff files.
• Put in place a robust medicine management system to ensure the safe storage of medicines and vaccines.

In addition the provider should:

• Put steps in place to ensure that the performance of the cleaning contractor is monitored.
• Continue to review and improve outcomes for patients experiencing poor mental health and those with long term conditions.
• Review arrangements for supporting patients with impaired hearing.
• Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to all.
• Revise the practice’s business continuity plan to include contact details for key staff members and consider arrangements for keeping copies of the plan stored off-site.
• Maintain records of all training undertaken by staff including training done internally, including infection control training and fire safety awareness training.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice