Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

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? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

The practice was inspected on 19 January 2017 and was found to be inadequate overall. The practice was rated inadequate in safe and well led, requires improvement in effective and responsiveness and good in caring. The practice was placed into special measures for a period of six months. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Willesborough Health Centre on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Willesborough Health Centre on 21 November 2017. The inspection was conducted to follow up on previous breaches of regulations identified in their earlier comprehensive inspection on 19 January 2017. Following the January 2017 inspection the practice was placed in special measures. At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice maintained up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
• We found the practice was clean and tidy and had systems in place to manage infection and prevention control.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• We found the practices clinical performance in the Quality and Outcome Framework had decline on their previous year, achieving 80% of the points available. The practice had not examined the reasons for the decline, attributing it to a change in personnel.
• Staff treated patients with compassion, kindness, dignity and respect.
• The GP partners had the skills and experience to manage the service effectively and staff had confidence in them.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The area where the provider should make improvement is:

• Continue to strengthen and embed systems to identify, assess, monitor and improve quality and safety of services.
• Improve the identification of carers.

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 comprehensive inspection at Willesborough Health Centre on 19 January 2017. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses to managers. However, reviews and investigations were not thorough enough. Records were not accountable and patients did not always receive an apology.
• Risks to patients were not always assessed and well managed.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. However, records were not fully accountable.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Not all staff had received the relevant training to keep patients safe.
• Not all staff had received annual appraisals and learning needs had not always been identified.
• Staff personnel and training records were not complete.
• The practice did not maintain standards of cleanliness.
• The management of medicines did not always keep patients safe.
• The majority of patients said they were treated with compassion, dignity and respect.
• The practice had a number of policies, procedures and risk assessments to govern activity, but some were overdue a review.

The areas where the provider must make improvements are:

• Investigate safety incidents and complaints thoroughly, ensuring that records are accountable, that patients affected receive reasonable support and a verbal and written apology. Implement lessons learned.
• Ensure that minutes from all meetings are recorded and accountable.

• Ensure that there are systems in place to manage Medicines and Healthcare Products Regulatory Agency (MHRA) patient safety alerts effectively.
• Ensure recruitment arrangements include all necessary pre-employment checks for all staff.
• Ensure that all staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
• Ensure all clinical and non-clinical staff have received training in safeguarding children and adults to the level required for their individual roles, fire safety and the Mental Capacity Act.
• Ensure that all the risks identified in the Legionella survey are addressed.
• Ensure that systems and processes effectively monitor expiry dates of medicines and equipment. Implement systems to monitor the cold-chain.
• Ensure that measures are taken to improve telephone access for patients.
• Ensure that appropriate standards of cleanliness are maintained, that infection control audits are conducted and that all staff receive relevant infection control training.

In addition the provider should:

• Introduce systems to proactively identify patients with caring responsibilities.
• Continue to improve systems for reviewing and updating risk assessments, procedures and guidance.
• Disseminate the newly implemented policy regarding chaperones to all staff.

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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice