We carried out an announced comprehensive inspection of The Greens Health Centre on 11 March 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We rated this practice as requires improvement overall but good for providing caring and responsive services and requires improvement for providing safe, effective and well-led services and requires improvement for all population groups with the exception of p

eople experiencing poor mental health (including people with dementia) which we rated as inadequate.

We found that:

Health and Safety Risk assessments were inadequate or missing.

• Patients received effective care and treatment that met their needs. However, the practice remained below local averages for the outcomes for patients with a long-term condition.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs.
• The formalisation of systems was required to further promote the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing safe services because:

• The safeguarding adult policy did not contain updated categories of abuse.
• Recruitment checks on locum staff had not been carried out in accordance with regulations.
• There was no active health and safety lead, no formal programme of risk assessments and a fire evacuation drill had not been carried out in the last 12 months.
• Patients on repeat medicines were not always receiving regular review.

We rated the practice as requires improvement for providing effective services because:

• Patient health outcomes were significantly below local averages in certain areas, for example, for patients experiencing poor mental health.
• There was no structured programme for the recording of clinical supervision.

We rated the practice as requires improvement for providing well-led services because:

• Health and safety arrangements required strengthening to promote a pro-active approach to risk management.
• There was no structured programme for clinical audit, a system for the recording of clinical supervision and a formal programme for learning and development, including for practice leaders.

The areas where the provider must make improvements are:

The regulations were not being met as the registered person had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. In particular:

• 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.

(please see the specific details on action required at the end of this report)

The areas where the provider should make improvements are:

• Continue to explore ways to further increase the uptake of cervical screening.
• Continue to review the patient satisfaction rates with telephone access.
• Review the training arrangements to support reception staff identify potential serious medical conditions that should be referred to a clinician immediately.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We previously inspected The Greens Health Centre on 10 November 2016. As a result of our inspection visit, the practice was rated as good overall and specifically for providing effective, caring, responsive and well-led services. However, the practice was rated as requires improvement for providing safe services. This was because we identified a regulatory breach in relation to regulation 12, Safe care and treatment and also in relation to regulation 13, Safeguarding service users from abuse and improper treatment. A requirement notice was issued to the provider in relation to these breaches. We identified some areas where the provider must make improvements, as well as areas where the provider should make improvements.

We carried out an announced focussed inspection at The Greens Health Centre on 9 August 2017. This inspection was conducted to see if improvements had been made following the previous inspection in 2016. You can read the reports from our previous inspections, by selecting the 'all reports' link for The Greens Health Centre on our website at www.cqc.org.uk.

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

• We saw minutes of monthly practice meetings which demonstrated that learning from significant events, incidents and complaints were shared with all staff; significant events were also discussed with staff once a significant event was raised.

• The practice had improved the systems in place to identify and review patients who frequently attended Accident and Emergency (A&E). We saw that these were reviewed on a daily basis and patients were followed up to determine if further assistance was needed. We also saw that patients that had attended A&E were discussed as part of the practices monthly multi-disciplinary team (MDT) meetings.

• We saw evidence to support that the practice nurses administered vaccines using patient group directions (PGDs) and PGDs were produced in line with legal requirements and national guidance. PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.

• We also saw evidence to confirm that legal patient specific directives (PSDs) were in place to support health care assistants role when administering vaccinations, such as flu vaccines. PSDs are written instructions signed by a prescriber, for medicines to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis.

• During our most recent inspection we also noted that the practice had improved in relation two additional areas identified where the practice should improve on our previous inspection. For instance, we saw that the practice started to audit their minor surgery service and we noted that the practice had taken action in response to the previous national GP patient survey published in July 2016.

• We saw that internal practice surveys were carried out to drill down on areas for improvement. Clinicians were monitoring their appointment times and a new telephone system was due to be installed in September 2017 to help improve telephone access. Furthermore, the results from the most recent national GP patient survey published in July 2017 highlighted that improvements were made across all areas of the survey.

• We observed the premises to be visibly clean. We also saw that the practice had displayed their previous CQC rating in compliance with Regulation 20A: Requirement as to display of performance assessments, to make sure the public and those who used the service could see them.

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 Greens Health Centre on 10 November 2016. Overall the practice is rated as good.

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

• During our inspection we saw that staff were friendly and helpful and treated patients with kindness and respect. Patients we spoke with during our inspection told us they were satisfied with the care and treatment they received.

• There were systems in place for reporting incidents, as well as comments and complaints received from patients. There were systems, processes and practices in place to keep people safeguarded from abuse.

• Staff we spoke with said that they worked closely as a team and communicated regularly on a daily basis but expressed that they would benefit from having a formal programme of practice meetings as a whole team.

• During our inspection the practice could not demonstrate how learning had been shared with practice nurses and non-clinical staff members since the last team meeting which took place in June 2016. We saw that a programme of meetings had been planned to improve this.

• We saw that that risks associated with safety were continually monitored, effectively mitigated and well managed.

• There was no evidence of legal patient specific directives (PSDs) in place for medicines to be supplied or administered (such as flu vaccinations) to patients by the health care assistant.

• Although the practice reviewed patients who frequently attended A&E, this was done on an adhoc basis and there was no systematic process in place to support this. Furthermore the practice did not frequently review child attendances at the local Accident and Emergency (A&E) departments.

• We saw evidence of some completed clinical audits in place which had been repeated to monitor quality and to make improvements.

• Patients could access appointments and services in a way and at a time that suited them. The practice operated open clinics and extended hours every Monday.

• The practice had reviewed there clinical rotas to ensure that patients had better access to continuity of care with a GP of their choice, as a result locums were rarely used and patients we spoke with during our inspection commented on good continuity of care.

The areas where the provider must make improvements are:

• Ensure that national guidelines are adhered to support clinical staff when administering vaccinations, implement patient specific directions (PSDs) and ensure that records are well governed to reflect PSD requirements including review, specification and authorisation.

• Embed a systematic process to ensure that patient (including child) attendance at A&E is regularly reviewed and followed up where necessary.

The areas where the provider should make improvements are:

• Use audits to identify and drive improvements across wider areas such as infection control and further areas of minor surgery.

• Sustain and continue to work on improving areas identified for improvement from the national GP patient survey responses.

• Continue to identify carers in order to provide further support where needed.
• Continue with the planned programme of regular practice meetings to support shared learning and team working as a whole practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We undertook this follow up visit in response to concerns that we had identified during our previous inspection of the service in 9 January 2014. Our visit was discussed and arranged with the provider in advance so that any disruption to people’s care and treatment were minimised.

At our previous inspection we had identified that the practice did not demonstrate how they learnt from incidents and complaints so that reoccurrences could be minimised and improvements made.

At this inspection we spoke with three staff members, the practice manager, a GP partner and five patients. We found that the provider had made progress in addressing issues identified in our last inspection. We saw that the provider had developed systems to learn from complaints and incidents so that improvements could be made.

We saw that efforts were being made to ensure that the service was responsive to the needs of patients by ensuring a GP was arriving on time for their shift.

We also saw that the practice had made changes to involve administration and receptions staff in meetings so that they were able to contribute. Staff told us that this helped to resolve the communication problems they had.

On the day of the inspection we spoke with one member of the reception staff, the practice manager and three GPs. We also spoke with five patients about their experience. Three members of the Patient Participation Group (PPG) had come in specifically to speak to us. However, we spoke with one of the members of the PPG.

Most of the patients we spoke with told us that care and treatment they had received was generally safe and appropriate. One patient we spoke with said: “Absolutely brilliant.” However, most patients said that they had to wait a long time after their appointment time. A patient we spoke with said: “It’s aright but a bit slow.” Some patients also expressed their dissatisfaction with the quality of consultation with specific GPs in the practice.

Appropriate guidance was available for staff to follow if abuse was suspected. Some staff had not received training in safeguarding adults but were booked to attend. Background checks for some clinical and administration staff were being made at the time of our visit to ensure that staff could work with vulnerable patients.

We found that staff were generally supported in the roles. This meant that they had been adequately assessed as being competent.

The practice did not demonstrate how they learnt from incidents and complaints so that reoccurrences could be minimised and improvements made.