This practice is rated as Good overall.

The Care Quality Commission (CQC) have previously carried out four inspections of the practice.

We carried out an announced comprehensive inspection at The Grange on 6 June 2016. The practice was rated inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 18 July 2016 for regulation 17 (good governance). The practice was placed into special measures for six months.

On 2 September 2016 we carried out a second inspection visit in response to information of concern about the provider who is also the registered manager and principal GP at 3Well Medical Ltd Botolph Bridge. We found the safety and leadership of systems for managing pathology and X-ray results and dealing with repeat prescriptions were not adequate. We did not rate this inspection.

A third inspection was carried out on 4 November 2016, to check on improvements detailed in the warning notice issued on 18 July 2016, following the inspection on 6 June 2016. We found the practice had reviewed their systems and strengthened their quality monitoring but could not demonstrate this was effective. A further warning notice was issued on the 22 November 2016 as appropriate systems were still not in place to assess, monitor, mitigate risks and improve the quality of the service. We did not rate this inspection.

A fourth inspection was undertaken following the period of special measures and included a follow up of the warning notice issued on 22 November 2016. It was an announced comprehensive inspection on 28 February 2017. Overall the practice was rated as requires improvement and was removed from special measures.

The full inspection reports can be found by selecting the ‘all reports’ link for The Grange on our website at .

This inspection was an announced comprehensive inspection carried out on 19 April 2018 to confirm that the practice had carried out the improvements identified at the last inspection in February 2017. Overall the practice is rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

At this inspection we found:

• The practice had continued to make improvements to ensure they were meeting the regulations and providing safe and effective services to patients.
• They had been able to recruit a new nursing team and pharmacist to join the practice and there had been an improvement in the retention of other staff. The provider was undertaking regular clinical sessions and regular locums were employed. Patients we spoke with and comment cards we received demonstrated they had been able to have continuity of care.
• Practice staff we spoke with told us they worked together to implement and embed the changes. They told us they had found the changes positive and said patients were receiving better service. This was confirmed by the patients we spoke with who stated the practice was more proactive in calling them in for reviews and the practice appeared calm and welcoming.
• The provider has another larger practice nearby and the management team had increased the use of technology to improve the clinical meetings and information sharing across both sites. This ensured all staff (most staff worked across both sites) were able to take part in the meetings.
• Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses and there was evidence of learning and communication with staff.
• The arrangements for managing medicines had been embedded to keep patients safe. The process for handling repeat prescriptions for high risk medicines ensured that patients were monitored regularly and that test results were checked before medicines were prescribed.
• The practice had systems and process in place to record and action safety alerts and had a system to regularly runs searches for effective monitoring.
• Risks to patients and staff which included fire, general risks and health and safety had been assessed and identified actions undertaken.
• Appropriate recruitment and induction checks had been completed for locum staff. A system was in place for recording and monitoring that mandatory training had been completed.
• 2016/2017 Quality and Outcomes Framework data showed patient outcomes had improved from the previous year and unverified 2017/18 data showed further improvements. Exception reporting had also significantly improved. Clinical audits had been carried out, and were driving improvements in patient outcomes.
• We found that some reviews and record keeping for patients experiencing poor mental health needed to be reviewed and improved. Some of the records we viewed did not contain cohesive note taking to ensure that information sharing was effective.
• The practice had a failsafe system in place for checking cervical cytology outcomes for patients and regular checks to ensure all samples were reported on.
• The appointment system was working well and patients told us they received timely care when they needed it.
• The practice had an active patient participation group (PPG) which included on line membership and members met with the practice on a regular basis.
• There was a wide variety of information displayed in the practice which had been translated into a number of languages used by patients including how to give feedback or complain.
• Governance systems had been improved, reviewed, and strengthened to ensure that the improvements could be sustained over time. The practice recognised where they needed to continue to further improve some areas and was working on these.

The areas where the provider should make improvements are:

• Review and improve the clinical record keeping in relation to annual reviews for patients who may be experiencing poor mental health.

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

Letter from the Chief Inspector of General Practice

This was the fifth inspection that we have carried out at The Grange. We carried out an announced comprehensive inspection at The Grange on 6 June 2016. The practice was rated inadequate overall, inadequate for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 18 July 2016 for regulation 17 (good governance). The practice was placed into special measures for six months.

On 2 September 2016 we carried out a second inspection visit in response to information of concern about the provider. The inspection on 2 September 2016 focused on the safe and well led key questions. We found the systems and processes for managing pathology and X-ray results and dealing with repeat prescriptions were not adequate.

A third inspection was carried out on 4 November 2016, to check on improvements detailed in the warning notice issued on 18 July 2016, following the inspection on 6 June 2016. We found that the practice had reviewed their systems and strengthened their quality monitoring but could not demonstrate this was effective. A further warning notice was issued on the 22 November 2016 as appropriate systems were still not in place to assess, monitor, mitigate risks and improve the quality of the service.

A comprehensive inspection was carried out on the 28 February 2017, following the period of special measures and to check on improvements detailed in the warning notice issued on the 22 November 2016, following the inspection on the 4 November 2016. The practice was rated as requires improvement overall. The full inspection reports on the June 2016, September 2016, November 2016 and February 2017 inspections can be found by selecting the ‘all reports’ link for The Grange on our website at www.cqc.org.uk.

This inspection was to check on improvements detailed in the warning notice issued on 8 March 2017, following the inspection on 28 February 2017. This report only covers our findings in relation to those requirements.

Our key findings from this inspection were as follows:

• An effective system for the monitoring and review of high risk medicines was in place.
• A process had been established to review and act on Medicines & Healthcare products Regulatory Agency (MHRA) alerts.
• There was an effective failsafe system in place for cervical cytology samples.

The areas where the provider should make improvement are:

• Consider the need to improve the clarity of roles and responsibilities in relation to managing patient safety alerts.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This was the fourth inspection that we have carried out at The Grange.

We carried out an announced comprehensive inspection at The Grange on 6 June 2016. The practice was rated inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 18 July 2016 for regulation 17 (good governance). The practice was placed into special measures for six months.

On 2 September 2016 we carried out a second inspection visit in response to information of concern about the provider. An inspection at another practice had identified that patient safety was being put at risk. Both practices shared a number of policies and procedures and several members of staff. The inspection on 2 September 2016 focused on the safe and well led domains. We found that areas of unsafe practice identified at the other practice, had ceased at The Grange. However, we found the safety and leadership of systems for managing pathology and X-ray results and dealing with repeat prescriptions were not adequate.

A third inspection was carried out on 4 November 2016, to check on improvements detailed in the warning notice issued on 18 July, following the inspection on 6 June 2016. We found that the practice had reviewed their systems and strengthened their quality monitoring but could not demonstrate this was effective. A further warning notice was issued on the 22 November 2016 as appropriate systems were still not in place to assess, monitor, mitigate risks and improve the quality of the service.

The full inspection reports on the June 2016, September 2016 and November 2016 inspections can be found by selecting the ‘all reports’ link for The Grange on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and included a follow up of the warning notice issued on 22 November 2016. It was an announced comprehensive inspection on 28 February 2017. Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• During part of the special measures period the principal GP had been unable to provide clinical services. Throughout the special measures period, the practice had received management support from the Royal College of General Practitioners team which consisted of GP and practice management support.
• Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses and there was evidence of learning and communication with staff.
• The arrangements for managing medicines needed to be fully embedded to keep patients safe. The process for handling repeat prescriptions for high risk medicines did not ensure that patients were monitored regularly and that test results were checked before medicines were prescribed. The practice was not following a system to recall patients on high risk medicines as stated in their policy.
• The practice had systems and process in place to record and action safety alerts. However some patients who may be affected by Medicines and Healthcare products Regulatory Agency (MHRA) alerts issued some years ago, had not been reviewed.
• Risks to patients and staff which included fire, general risks and health and safety had been assessed and identified actions undertaken.
• Appropriate recruitment and induction checks had been completed for locum staff. A system was in place for recording and monitoring that mandatory training had been completed.
• On the day of the inspection the practice had not been successful in recruiting further GP partners or salaried GPs. They had engaged locum GPs and advance nurse practitioners who provided sessions on a regular basis. They told us they were in discussion with staff in relation to joining the team, but on the day of the inspection the staff had not signed any contracts. The systems to provide clinical supervision for clinical staff needed to be improved.
• 2015/16 Data showed patient outcomes were low compared to the national average, however 2016/17 unverified data showed significant improvements. Although some clinical audits had been carried out, there was limited evidence that audits were driving improvements in patient outcomes. Following the inspection, the practice informed us that they consider regular QOF reviews as part of their clinical audit process. Unverified data for 2016/2017 showed an improvement in their performance.
• The practice previously had a failsafe system in place for checking cervical cytology outcomes for patients; however this had not been completed since 2 September 2016.
• A staff member had taken a lead role as a carer’s champion and the support and information available to carers had significantly improved. The practice had identified 56 carers (just under 2% of the practice list) compared to 15 at the inspection in June 2016.
• The appointment system was working well and patients told us they received timely care when they needed it.
• The practice had an active patient participation group (PPG) which included on line membership and members met with the practice on a regular basis. The PPG gave examples of where the practice had responded to patient feedback and made improvements and where the PPG had directly undertaken improvements.
• Some information was displayed in the practice which had been translated into a number of languages used by patients.
• Patients were informed that there was a complaints process, however further information was not easily available to patients and it was not available in other languages used by registered patients. Information on the complaints system was not up to date on the website.
• Governance systems had improved but the practice needed additional time to review, strengthen, and embed their new process to ensure that the improvements could be sustained over time.

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

Importantly, the provider must:

• Ensure systems and processes are in place to assess, monitor and improve the quality and safety of the service, including for example MHRA alerts which remain relevant, high risk medicines and cervical cytology.

In addition the provider should:

• Ensure that checks are undertaken and documented to provide assurance of the quality of the work undertaken by locum staff and improve arrangements for clinical supervision.
• Ensure that the patient information leaflet on complaints is easily available to patients and that complaints information on the practice’s website is up to date.
• Continue to work on translating information into languages used by patients at the practice.
• Ensure that all staff know how to find practice policies and procedures.

This service was placed in special measures in September 2016. 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

This was the third inspection that we had carried out at The Grange. Our first visit took place on 6 June 2016 when we completed a comprehensive inspection. The practice was rated as inadequate overall and rated as requires improvement for providing  caring and responsive services and inadequate for safe, effective and well led services. As a result of the findings on the day of the inspection the practice was issued with requirement notices for Regulation 12 (Safe care and treatment) and Regulation 19 (Fit and proper persons employed). We also found that the systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others. As a result of these findings the practice was issued with a warning notice for Regulation 17 (Good governance) on 19 July 2016 and asked to achieve compliance by 23 September 2016.

On 2 September 2016 we carried out a second inspection visit in response to information of concern we had received about the provider who is also the registered manager and principal GP at a second practice, 3Well Medical Ltd Botolph Bridge. An inspection at 3Well Medical Botolph Bridge had identified that patient safety was being put at risk. Both practices shared a number of policies and procedures and several members of staff worked at both locations. The inspection on 2 September 2016 focused on the safe and well led domains. We found that areas of unsafe practice identified at 3Well Medical Ltd, had ceased at the Grange. However the safety and leadership of systems for managing pathology and X-ray results and dealing with repeat prescriptions were not adequate. The practice was placed into special measures in September 2016.

On the 4 November 2016, we conducted a focused inspection to ensure that the practice had made the required improvements detailed in the warning notice that had been issued on 18 July following our inspection on 6 June 2016. The provider stated that the warning notice had not been received until two weeks prior to our visit.

During our visit we found that the practice had reviewed their systems and taken steps to strengthen the quality monitoring procedures they used for managing services. However, they were unable to demonstrate that all of the improvements had been completed or that they were effective. 

We found the provider had not taken all the required actions in order to achieve compliance with the warning notice issued on 19 July 2016. Further enforcement action is being taken and the practice remains in special measures for a period of six months commencing 13 September 2016.

This report covers our findings in relation to our focused inspection. you can read our findings from our last inspections by selecting the ‘all reports’ link for The Grange on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This was the second inspection CQC has undertaken at The Grange.

On 6 June 2016, we carried out a comprehensive inspection of The Grange. The practice was rated as inadequate overall and rated as inadequate for providing safe, effective and well led services and requires improvement for caring and responsive services. As a result of the findings on the day of the inspection, the practice was issued with warning notices for Regulation 17 (Good governance) and requirement notices for Regulation 12 (Safe care and treatment) and Regulations 18 (Fit and proper persons employed). The practice was placed into special measures for six months.

On 2 September 2016, we conducted an announced focused inspection. This inspection was undertaken because we had received information of concern about the provider. The provider at The Grange is also the Registered Manager and GP principal at a second practice (3Well Ltd Botolph Bridge). During a recent inspection at 3Well Ltd Botolph Bridge the provider was found to be putting patients at risk. We gathered evidence that showed that the lead GP, practice manager and practice staff, worked across both sites. We saw that the management team shared policies and procedures across both sites.

This report covers our findings in relation to our focused inspection which covered the safe and well led domain. You can read our findings from our last inspections by selecting the ‘all reports’ link for The Grange on our website at www.cqc.org.uk.

The key findings from our inspection on 2 September 2016 across all the areas we inspected were as follows:

• During our inspection of the provider’s second practice (3 Well Ltd Botolph Bridge) we found that staff were piloting a new model of care, which we were concerned placed patients at risk of harm. Following our inspection NHS England suspended this pilot. We found evidence that The Grange had previously operated this model of care. However the practice gave reassurance that this model was no longer in use at The Grange.

• During our inspection of the provider’s second practice (3 Well Ltd Botolph Bridge), we found that the management of pathology and X-ray results was not well managed and put patients at risk of sub optimal care. On this inspection we found evidence that the provider was using a similar system and the same staff members. We did not find a delay in the processing of results, but found that the governance, policy, and procedures were not sufficiently robust.

• During our inspection of the provider’s second practice (3 Well Ltd Botolph Bridge), we found that the practice employed staff to manage patient’s medicines. They had not put a governance framework, practice policy, and procedure in place to ensure that patients were kept safe. This put patients at risk of harm. On this inspection we found evidence to show that the practice staff had performed medicines reviews and had re-authorised medicines, but that this approach had been discontinued. However, we found that the governance relating to the safe management of medicines needed to be improved.

This service was placed in special measures in September 2016 and this arrangement continues for 6 months.

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 The Grange on 6 June 2016. Overall the practice is rated as inadequate

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

• The practice had been through a period of staff changes following the retirement of a GP partner and a change of practice manager. Staff were working hard to maintain a family centred service with long term locum GPs and a locum nurse practitioner.

• Staff worked with patients to provide a service they valued.
• Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses and there was evidence of learning and communication with staff. Patients received an apology when things went wrong.

• Patient safety was not secure because several systems and processes were not robust. For example appropriate recruitment and induction checks had not been completed for locum staff, systems to monitor patients safeguarding needs were not sufficient and infection control procedures required strengthening. Clinical audits and checks of some administrative procedures such as issuing repeat prescriptions were not in place.

• Data showed patient outcomes were low compared to the national average. Although some clinical audits had been carried out, we saw no evidence that audits were driving improvements in patient outcomes.

• The majority of patients who completed CQC comments cards or gave feedback during the inspection said they were treated with compassion, dignity and respect. However, results from the last GP patient survey indicated that not all patients felt cared for, supported and listened to.

• The appointment system was working well and patients told us they received timely care when they needed it.

• There was a leadership structure in place but there was insufficient leadership capacity and formal governance arrangements to monitor and support the service.

The areas where the provider must make improvements are:

• Ensure that procedures are in place to identify, support and review patients who may require protection due to safeguarding concerns.

• Review the systems in place for issuing repeat prescriptions particularly for patients receiving high risk medicines.

• Review emergency equipment to ensure that there is an accessible oxygen mask suitable for use in children and there is suitable equipment for measuring blood glucose levels. Regular checks of all emergency clinical items must be recorded.

• Minimum and maximum temperatures of the medicines fridges should be monitored and recorded.
• Assess the risks of legionella and fire in the building and ensure that adequate control measures are implemented.

• Implement a clear system to monitor the completion of staff training relevant to their roles and responsibilities. This should include assurance that appropriate staff have completed training in chaperoning, safeguarding adults and children and infection control.

• Establish systems to monitor infection control practice so that identified improvements can be made in a timely manner.

• Ensure that the recruitment policy is reviewed to checks for all staff (including locum staff) and evidence that induction procedures have been completed.

• Improve governance arrangements so that staff remain informed about changes in national guidelines, performance against quality measures such as QOF, clinical and other internal service audits so that quality and safety improvements can be actioned.

In addition the provider should:

• Provide updated information in suitable formats for patients about the complaints process.
• Ensure that staff are familiar with the role of the controlled drugs accountable officer and when to report incidents.
• Ensure that all relevant safety alerts and the actions required are discussed with staff at practice meetings to maintain safe care and treatment.
• Review systems used to identify patients with caring responsibilities and ensure that relevant information about support systems are accessible to them.
• Consider providing key service information in alternative languages to suit the practice population.

As a result of the findings on the day of the inspection the practice was issued with warning notices for Regulation 17 (Good governanace). We will return to ensure that the practice has complied with this warning notice as soon as it has expired.

I am placing this service in special measures.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it 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 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.

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