We carried out an announced comprehensive inspection at St Mary’s Urgent Care Centre (UCC) on 13 July 2017. The overall rating was inadequate and the provider was placed in special measures for a period of six months. In addition, we took enforcement action in the form of a warning notice in respect of good governance and informed the provider that they must become complaint with the law by 18 August 2017.

In response to the enforcement action taken, the provider sent us an action plan outlining improvements that had been put in place since our previous inspection. We then carried out an announced focused follow-up inspection on 22 August 2017 to check that the necessary improvements had been made in respect of the warning notice, or whether further enforcement action was required. At the inspection we found improvements had been made to prevent further enforcement action.

The comprehensive report for the July 2017 inspection and the report of the focused follow-up inspection in August 2017 can be found by selecting the ‘all reports’ link for St Mary’s Urgent Care Centre on our website at www.cqc.org.uk.

This inspection, carried out on 27 March 2018, was an announced comprehensive inspection to review in detail the actions taken by the provider since our July and August 2017 inspections to improve the quality of care and to confirm that the provider was now meeting legal requirements.

Overall the provider is now rated as Requires Improvement.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

At this inspection we found:

• The provider had addressed the findings of our previous inspection and was able to demonstrate improvements in safeguarding, staffing, fire safety and systems and process for the sharing of learning and outcomes from significant events and patient safety alerts.
• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. All staff had been trained to a level appropriate to their role.
• There was an open and transparent approach to safety and systems were in place for recording and reporting significant events. An effective process to share learning with staff had been implemented.
• Systems had been introduced to manage patient safety alerts and staff were able to give examples.
• The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and had improved their processes.
• The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The provider demonstrated an understanding of the service’s performance and had made considerable improvements in some of its performance targets. However, there was evidence that one target was still not being met which impacted on patients receiving care and treatment in a timely manner and had a potential impact on other services.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from patients and staff, which it acted upon.
• The provider was aware of the duty of candour and examples we reviewed showed the service complied with these requirements.
• The service told us its strategy for the next 12 months was to maintain the improvements it had made since our last inspection. However, there was no formal strategy to provide assurance of resilience to support its priorities for delivering good quality sustainable care.

The areas where the provider must make improvements as they are in breach of regulations are:

• 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:

• Maintain oversight of the significant incident reporting process to ensure these are managed within the appropriate timeframe.

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 carried out an announced focused inspection of St Mary's Urgent Care Centre (Vocare Limited) on 22 August 2017. This was to follow-up on a warning notice the Care Quality Commission served following an announced comprehensive inspection on 13 July 2017 when the provider was rated as inadequate for providing well-led services.

The warning notice, issued on 20 July 2017, was served in relation to regulation 17: Good Governance of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notice was 18 August 2017.

The inspection on 13 July 2017 highlighted several areas where the provider had not met the standards of regulation 17: Good governance. We found:

• Systems and processes were failing to ensure accurate reconciliation of all patient x-rays.

• Systems and processes were failing to ensure effective clinical review of all x-rays.

• Systems and processes were failing to ensure effective recall of all patients with missed fractures.

• Systems and processes were failing to alert the provider to the backlog of x-ray clinical reviews. 

• Systems and processes were failing to ensure that learning and outcomes from all categories of significant incidents were effectively shared and monitored.

At this inspection on 22 August 2017 we found that actions had been taken to improve the provision of well-led services in relation to the warning notice. Specifically the provider had:

• Undertaken a reconciliation of all patient x-rays in liaison with the hospital trust.
• Ascertained the number of patients whose x-ray had not been cross-checked by the urgent care centre (UCC) team and created a single patient database.
• Undertook a clinical review of each patient's consultation and x-ray result to identify any missed fractures.
• Contacted all patients by letter who had been identified as having a missed fracture.
• Re-established its standard operating procedure for the monitoring of x-rays.
• Implemented a daily risk management meeting within the UCC which included monitoring of x-rays. 
• Re-established its systems and processes to ensure learning and outcomes from all categories of significant incidents were effectively shared with all staff and monitored to prevent the same thing happening again.

At our previous inspection on 13 July 2017, we rated the provider as inadequate for the provision of safe, effective and well-led services with an overall rating of inadequate. The provider was placed into 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 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.  

Our inspection on 22 August 2017 focussed on the concerns giving rise to a warning notice being issued on the 20 July 2017. We found that the provider had taken action to address the breaches of regulation set out in the warning notice. However, the current overall inadequate rating will remain until the provider receives a further comprehensive inspection to assess the improvements achieved against all breaches of regulation identified at our previous inspection.

The comprehensive report published on 5 October 2017 should be read in conjunction with this report.

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 St Mary’s Urgent Care Centre (Vocare Limited) on 13 July 2017. Overall the service is rated as inadequate.

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

• Systems and processes were failing to identify all incidents and ensure that learning and outcomes were effectively shared to prevent the same incidents happening again. Opportunities to prevent or minimise harm were missed as there was insufficient oversight and monitoring of ongoing incidents and risks both at local and organisational level.
• There was insufficient attention to safeguarding children and vulnerable adults. We found that processes were not clearly defined or embedded.
• The provider demonstrated an effective recruitment system for substantive and agency staff. However, the arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs had been inconsistent and there were periods of understaffing.
• The provider had insufficient assurances in place to demonstrate that people received effective care. This included a system to ensure clinicians were up-to-date with and following current evidence-based guidance and that regular reviews of clinical notes were undertaken.
• The provider demonstrated an understanding of the service’s performance. However, it had failed to achieve some of its performance targets.
• There was limited evidence that clinical audit was driving improvement to patient outcomes.
• Staff had not received a formal appraisal necessary to enable them to carry out their duties although the provider demonstrated it had commenced one-to-one meetings with staff in preparation for an appraisal.
• On the day of the inspection we observed members of staff were courteous and helpful to patients and treated them with dignity and respect.
• Information about how to complain was available to patients and we saw that complaints had been handled in a timely manner and in line with national guidance.
• The provider had undertaken limited patient engagement to obtain the views of people who use the service.
• Although the service had an overarching organisational governance framework this had not been implemented adequately at a local or organisational level to ensure the delivery of good quality care and opportunities to prevent or minimise harm were missed.
• There had been a lack of clear management and clinical leadership and staff had not felt supported in their day-to-day roles. However, staff told us communication and engagement had improved since the interim management team had been in place.
• We saw evidence that the provider had complied with the Duty of Candour (the duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment) and contacted patients potentially affected by recent breaches of the cold chain and those where there had been a delay in identifying a missed fracture.

The areas where the provider must make improvement 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.
• 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.

The areas where the provider should make improvement are:

• Consider the infection control lead undertaking enhanced training to support them in this extended role.
• Review the fire evacuation procedure to ensure all staff understand, and continue to understand, the plan in the event of a fire.
• Review auditory privacy at all points of patient access to the service.
• Review how patients with a hearing impairment would access the service.
• Consider providing patient literature in languages aligned to the identified patient demographic.

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 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