30/09/2015
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an unannounced focused inspection at Kirkby Community Primary Care Centre on 30 September 2015. The inspection was to follow up warning notices we issued after an inspection on 13 May 2015 from which overall services provided at the practice were rated inadequate and the location was placed into special measures.
We found the provider to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The regulations breached were:
Regulation 12: Safe care and treatment
Regulation 17: Good governance
As this was a follow up inspection we looked at the areas we identified in the warning notice which were about safe care and treatment to see if the improvements had been made. During the inspection we saw other areas of serious concern.
Our key findings were as follows:
- The provider had made improvements to the calibration and safety testing of equipment.
- Care plans for patients who were at risk of unplanned admission to hospital had been implemented.
- A new system of recording incidents, near misses and concerns had been implemented although it was too early to assess the effectiveness.
- We saw patients had not received essential medicines they needed to treat their condition.
- Children had been put at risk of unsafe care due to the provider’s poor and increasingly worsening performance in administering childhood vaccinations.
- A number of patients had received medicines without any monitoring of their health or in line with their treatment plan.
- The poor governance of record management and lack of oversight for safeguarding children could put them at increased risk of harm.
- There were historic and widespread errors with the accuracy of clinically coding health records which had led to missed opportunities for health screening and safe treatment of patients.
In relation to all of the areas of concern identified, the provider (Central Nottinghamshire Clinical Services) and NHS commissioning organisations were informed to ensure any of the risks identified during our inspection were investigated. We also informed the local authority safeguarding team of our findings.
Following our inspection, due to the serious concerns identified we urgently varied the conditions of provider’s registration with the Care Quality Commission (CQC) and stopped the provider providing GP services at Kirkby Community Primary Care Centre on 2 October 2015.
If the provider was still able to provide GP services at Kirkby Community Primary Care Centre we would have told them they must have made the following improvements:
- The process for providing care and treatment to patients must be carried out in a safe way and to nationally recognised standards.
- Review care records and assess the risks to the health and safety of patients who use the practice.
- Ensure that any incidents that affect, or have affected, the safe care and treatment are recorded, investigated and learnt from.
- Where incidents that have caused harm are identified. Those affected must be told in line with duty of candour.
- Ensure the prescribing, and oversight, of medicines is safe and effective.
- Ensure that medicines are stored in line with manufacturer’s instructions.
As part of our action we liaised with NHS England and NHS Mansfield and Ashfield Clinical Commissioning Group. This ensured that patients had continued access to GP services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice