We carried out an announced comprehensive inspection at Welland Medical Practice on 29 November 2018 as part of our inspection programme. The practice was previously inspected in April 2016 and rated as good overall and for providing effective, caring, responsive and well led services and rated as requires improvement for providing safe services. We undertook a desk top review of the safe domain in September 2016 and rated the practice as good for providing safe services.

Our inspection team was led by a CQC inspector and included a GP specialist advisor.

Our judgement of the quality of care at this service is based 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 have rated this practice as inadequate overall.

We concluded that:

• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• The practice operated from premises that no longer met the needs of the local population. The practice was actively working with the Clinical Commissioning Group to ensure that new premises that were being built nearby were completed and they told us they should move into them by end of April 2019.

However, we also found that:

• People were not adequately protected from avoidable harm and abuse.
• There was insufficient assurance that people received effective care and treatment.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

We rated the practice as inadequate for providing safe services because:

• The practice failed to evidence they had recruited staff safely.
• The practice did not provide evidence to demonstrate they had an effective induction system in place for new staff members. The provider had not ensured all staff had been appropriately trained to undertake the clinical tasks delegated to them.
• The practice had not ensured patient specific directions were signed prior to the healthcare assistant administering injections.
• GPs did not regularly attend safeguarding or multidisciplinary meetings that were held to discuss their patients. Minutes of the meetings were circulated to the GPs after the meeting for information.
• The practice was up to date on the summarising of medical records but they did not have a system in place to ensure they monitored the quality of the coding made by non-clinical staff or a system in place to monitor any delays in referrals and mitigate any risks.
• The practice had not implemented effective systems to ensure appropriate and safe handling of medicines or emergency medicines.
• The practice systems and processes to ensure all actions identified from significant events were actioned and monitored needed to be improved. There was no clear evidence to demonstrate identified learning was shared with the whole practice team.
• The practice had not undertaken regular water sample tests and could not provide evidence to demonstrate they regularly undertook water temperature tests to monitor and manage the risk of Legionella.

We rated the practice as inadequate for providing effective services because:

• The monitoring of some of the outcomes of care and treatment needed to be improved. For example, the practice performance in relation to prescribing hypnotics was above the CCG and national average. The practice had not undertaken any reviews or monitoring such as clinical audit to ensure they were prescribing effectively.
• The provider did not demonstrate that all staff had the skills, knowledge and experience to carry out their roles. The management team did not have clear clinical oversight of the training needs and competency of staff.
• Due to the shortage of trained staff, the practice had offered limited access to appropriate health assessments and checks including NHS checks for patients aged 40-74. For example, the practice had undertaken 11 NHS reviews, and no reviews for carers or reviews for patients with learning disabilities.
• The practice held regular monthly meetings with the health visitor and school nurse to discuss concerns however the GPs did not regularly attend these meetings but kept up to date via the minutes that were recorded and shared with them.
• The practice had not reviewed the uptake of the national screening programme in relation to breast and bowel cancer. Both indicators were below the CCG and national averages, the practice did not have systems and processes in place to encourage uptake.

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

• Generally, feedback from patients showed that staff did not always treat patients with kindness, respect and compassion.

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

• Data from the 2018 GP Patient Survey showed patients satisfaction regarding access to the practice was statistically comparable with other practices; however, most indicators were below the CCG and national averages. Some comments on NHS choices and on the comment cards we received reported negative experiences.
• The practice took complaints and concerns seriously; however, they did not always respond to them appropriately to improve the quality of care. We found little evidence to show the practice reviewed complaints or ensured actions identified were completed or learning was shared with the whole practice team.

We rated the practice as inadequate for providing well led services because:

• The provider had not ensured care and treatment was provided in a safe way to patients.
• People were not adequately protected from avoidable harm and abuse.
• The provider was unable to assure themselves that people received effective care and treatment.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

The areas where the provider must make improvements are:

• Ensure that 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.

The areas where the provider should make improvements are:

• Review the uptake of the national screening programme to encourage patients to attend their screening programmes.
• Review and improve the system to identify carers to ensure they receive appropriate support.
• Review the practice end of life care register to ensure patients are reviewed and removed from the list if appropriate.

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

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.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 5 April 2016. We set a requirement in relation to Safe Care and Treatment. The practice sent in an action plan informing us about what they would do to meet legal requirements in relation to the following;

• Robust processes were not in place to assess the risk of and prevent, detect and control the spread of infection.
• The practice did not have a robust legionella risk assessment and did not ensure regular infection control audits were fully completed.

They told us these issues would be addressed by 31 May 2016 and provided us with evidence to show they had taken the action to address the concerns.

We undertook a desk top review on 19 September 2016 to make a judgement about whether their actions had addressed the requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for 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

We carried out an announced comprehensive inspection at Welland Medical Practice on 5 April 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach and an effective system in place for reporting and recording significant events.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Urgent appointments with a GP were available on the same day.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.
• The practice was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are;

• Ensure the practice has a robust Legionella risk assessment.
• Ensure regular infection control audits are fully completed.

The areas where the provider should make improvements are;

• Ensure practice specific policies are reviewed regularly.
• Ensure regular fire drills take place to practice the fire evacuation procedure.
• Take more proactive steps to improve breast and bowel screening rates.
• Ensure the practice is proactive in Identifying Carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice