We carried out an announced comprehensive inspection at Market Hill 8 – 8 Surgery on 22 June 2017. The overall rating for the practice was inadequate and the practice was placed into special measures. Services placed in special measures are routinely inspected again within six months. The full comprehensive report for the June 2017 inspection can be found by selecting the ‘all reports’ link for Market Hill 8 – 8 Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive carried out on 27 February 2018 to check whether the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection looked at the five key questions of safe, effective, caring, responsive and well led.

This practice is rated as Requires Improvement overall. (Previous inspection June 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

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 recently 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

At this inspection we found:

• Systems, processes and practices were mostly in place to keep patients safe.
• Performance data overall was below the local CCG and England average. There were examples where uptake for screening programmes was below local and national averages.
• The practice had a comprehensive programme of quality improvement activity and had begun to routinely review the effectiveness and appropriateness of the care provided.
• Practice staff worked with a range of health and care professionals in the delivery of patient care and was proactive in identifying opportunities to promote and support patients to lead healthier lives. For example partnership working with a local school.
• Staff told us they were committed to treating patients with compassion, kindness, dignity and respect. Recent evidence was mostly positive in respect of the way patients were treated. However, the national patient survey results remained lower than average.
• Patient feedback was mostly positive about the ease of obtaining an appointment. However results from the national GP patient survey published in July 2017 showed that patient’s satisfaction to questions on how they could access care and treatment was significantly below local CCG and national averages in five out of the six questions asked. The practice was aware of the need to review timely access to clinical staff and had begun to take action to review and address this.
• New practice management and lead Director roles had been put in place. The result of this had started to show improved outcomes for patients and staff.
• Many of the changes introduced as part of the practice improvement plan and CQC action plan were in their infancy but showing signs of clear improvement. Quality improvement was high on the agenda for the practice and systems and plans were in place to deliver further improvement and address areas that still required improvement.

The areas where the provider should make improvements are:

Ensure that staff fully understand their role in reporting safety incidents and that all incidents are reviewed appropriately.

Review the current arrangements for ensuring safety alerts are received by the practice and that the system provides assurance they are responded to appropriately.

Review the arrangement currently in place for ensuring patients aged over 75 years of age are offered an annual health check.

Review the approach to screening programmes that are below local and national averages with the aim of improving uptake and coverage.

Have in place a system to assess the prescribing competence of the practice nurse prescriber.

Review the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if appropriate.

The practice should ensure that the new governance arrangements in place are embedded into practice so that improvement is sustained and further improvement/risk is identified and addressed.

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

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Market Hill 8 – 8 Centre on 6 January 2016 under the previous provider Danum Medical Services. The practice was rated inadequate. Following the inspection, due to the serious concerns identified we urgently varied the conditions of the provider’s registration with the Care Quality Commission (CQC) under section 31 of the Health and Social Care Act 2008 and stopped the provider Danum Medical Services Limited (DMSL) from providing GP services at Market Hill 8 - 8 Centre from 12 January 2016.

Core Care Links Limited was brought in by NHS England to provide emergency cover shortly after the inspection. NHSE awarded Core Care Links Limited the contract to provide services from Market Hill 8 – 8 Centre in April 2016 for 12 months. This contract has been awarded again and runs for a further 12 months. Core Care Links Limited is a company that provides emergency primary care on behalf of the North East Lincolnshire Clinical Commissioning Group (NELCCG). The company operates as a social enterprise, i.e. it is not for profit. The five Directors are local practising GPs, four of whom work at Market Hill.

We carried out an announced comprehensive inspection at Market Hill 8 – 8 Surgery on 22 June 2017 under the new provider Core Care Links Limited. Overall the practice is rated as inadequate.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when things went wrong reviews and investigations into significant events were not thorough enough and lessons learned were not communicated widely enough to support improvement. There was limited evidence to demonstrate the practice had a system in place to revisit changes introduced to assure themselves that the changes were effective and embedded into practice over time.
• Patients were at risk of harm because systems and processes had weaknesses and were not always effectively implemented in a way to keep them safe. Areas of concern related to medicines management, dealing with emergencies, management of unforeseen circumstances, training and management of patient confidentiality.
• The most recent published QOF results were 88% of the total number of points available which was lower when compared with the clinical commissioning group (CCG) average of 97% and national average of 95%. Exception report was 13.5%, above the CCG average of 8% and comparable to the England average of 10%. The provider provided evidence of QOF data for 2016/2017 which had not been published yet which showed improved performance from 88% to 97%. Exception reporting had improved. QOF (Quality and Outcomes Framework) is a system intended to improve the quality of general practice and reward good practice).
• Four self-employed GPs worked at the practice on a sessional basis. They did not attend clinical team meetings and were not supervised by the practice directors. Mentorship arrangements were in place for the practice nurse and advanced nurse practitioner.
• Staff said they had access to appropriate training to meet their learning needs. We saw evidence to show that staff were supported to develop into new roles. Despite this, the practice could not demonstrate how they ensured mandatory training and update training was completed for all staff. Gaps were identified in mandatory training such as infection control, fire safety, anaphylaxis and basic life support. These gaps put patients at risk. We saw evidence that basic life support and anaphylaxis training had been booked for the middle of July 2017.
• The information needed to plan and deliver care and treatment was not always available to relevant staff in a timely and accessible way through the practice’s patient record system and their intranet system. For example there was a backlog of letters that required coding and patient records that required summarising. We noted a plan was in place to reduce the summarising backlog.
• The majority of patients said they were treated with compassion, dignity and respect.
• The practice was open between 8am and 8pm Monday to Saturday and 10am to 2pm on a Sunday. GPs offered telephone triage, same day and routine appointments on a daily basis and on a Saturday a sit and wait service was available between 1pm and 3pm. One GP was on duty at any given time.
• Results from the national GP patient survey published in July 2017 showed that patient’s satisfaction to questions on how they could access care and treatment was below local CCG and national averages in six out of the seven questions asked.
• The practice had a practice improvement plan in place which reflected the vision and values and was regularly monitored although this did not accurately reflect our findings.
• The practice has good vision but governance implementation is poor, lack of clear corporate and clinical governance leadership. Despite the issues we identified for improvement there was a focus on continuous learning and improvement at all levels within the practice. It was evident the directors were focused on delivering improvement for the patients at Market Hill and despite the contractual challenges the provider was progressing with initiatives to deliver some of this.

The areas where the provider must make improvements 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 persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

In addition the provider should:

• Review the arrangements in place for referring patients to other services for further investigation/support.
• Review the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if appropriate.
• Review the availability of non-urgent appointments, waiting times and continuity of care.
• Ensure staff fully understand their role in the chaperone process.
• Review the arrangements for managing complaints.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice