Brotton Surgery

We carried out an announced, comprehensive inspection of ELM Alliance Limited on 25 January 2018. We identified two breaches of regulations and issued a warning notice for one of the breaches. This focused inspection carried out on 13 September 2018 was an announced focussed follow-up inspection, without ratings, to check whether the provider had taken steps to comply with the legal requirements for this breach of:

• Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing

This report covers our findings in relation to those requirements.

The full comprehensive report on the January 2018 inspection can be found by selecting the ‘all reports’ link for Hirsel Medical Centre – ELM Alliance on our website at www.cqc.org.uk.

Our key findings were as follows:

Overall improvements had been made with respect to the management of staffing following our last inspection on 25 January 2018. For example:

• Improvements had been made with regard to effective governance within the service. For example, training and recruitment records were centrally recorded and all staff received a corporate induction to the service.
• Supervision sessions for clinical and non-clinical staff were held on a monthly basis and records of attendance kept in a centrally managed record.
• The provider had satisfied themselves that all clinical staff had medical indemnity which covered them for the correct number of clinical sessions.
• The provider had introduced the use of a risk management tool for reporting of incidents. This had increased the effectiveness of reporting, lessons learned and feedback to staff.

On the day of inspection, 13 September 2018, the inspection team found that the provider was compliant with the breach of regulation previously identified in January 2018. (Regulation 18 Health and Social Care Act 2008(Regulated Activities) Regulations 2014: Staffing)

As this September 2018 inspection focussed only on the improvements from the issued warning notice, further comprehensive inspections of the locations, including all five key lines of enquiry, will take place in the coming months.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This service is rated as requires improvement overall. (Previous inspection July 2017 – Inadequate)

The key questions are rated as:

Are services safe? – requires improvement

Are services effective? requires improvement

Are services caring? – Good

Are services responsive? – requires improvement

Are services well-led? –requires improvement

We carried out an unannounced comprehensive inspection at ELM Alliance Limited on 11 and 12 July 2017. The overall rating for the service was inadequate. This service was placed in special measures in September 2017. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Park Surgery – ELM Alliance Limited on our website at www.cqc.org.uk. A further focussed inspection was undertaken in November 2017, where we followed up concerns from the three warning notices we had issued. That re-inspection was not given a rating but we were satisfied that risks had been sufficiently reduced at that time.

This inspection was an announced comprehensive follow up inspection carried out on 25 January 2018 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections.

Overall the service is now rated as Requires Improvement

Our key findings were as follows:

• The service ensured that care and treatment was delivered according to evidence- based guidelines.

• Staff involved and treated people with compassion, kindness, dignity and respect.

• Patients told us through CQC questionnaires, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

• Patients could access treatment and care at any time within a 24 hour period (when referred by NHS111).

The areas where the provider must make improvements as they are in breach of regulations are:

• The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

• The provider must deploy sufficient numbers of suitably qualified, competent, skilled and experienced persons, ensuring they 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.

The areas where the provider should make improvements are:

• The provider should undertake a regular review of the staffing rota, ensuring that staffing numbers are adequate, and closely monitor absence and lateness.

• The provider should review the chaperone policy as it did not fully outline the necessary procedures and required some improvement to make it effective.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this 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 of ELM Alliance Limited on 11 July 2017 and 12 July 2017. We identified six breaches of regulations and issued warning notices for three of the breaches. This focused inspection carried out on 9 November 2017 was to check whether the provider had taken steps to comply with the legal requirements for these three breaches. The three breaches of regulation we inspected against were for:

• Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and Treatment.

• Regulation 13 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safeguarding Service Users from Abuse.

• Regulation 17: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance.

The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Park Surgery – ELM Alliance on our website at www.cqc.org.uk.

This inspection was an unannounced focused inspection carried out on 9 November 2017 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 11 and 12 July 2017. This report covers our findings in relation to those requirements.

Our key findings were as follows:

Improvements had been made with respect to patient safety, effectiveness and leadership following our last inspection on 11 and 12 July 2017. For example:

• New processes had been put in place to report and manage significant events and safeguarding concerns.

• Patient safety and medicines alerts were being received, assessed and when necessary, actioned appropriately.

• Improvements had been made with regard to effective governance and management within the service. For example, training and recruitment records were centrally recorded and all staff received an induction to the service.

• Health and safety risk assessments were underway.

However, there were also areas of practice where the provider needed to make improvements:

The provider must:

• Ensure that entries of medicines are correctly and fully recorded in the controlled drugs’ register.

• Check stock balances of controlled drugs on a weekly basis, in accordance with the provider’s own policy, to ensure that amounts held reflect what has been entered into the controlled drugs’ register.

• Ensure that quantities of medicines supplied are clearly indicated in records and on prescriptions.

The provider should:

• Have a system in place to check expiry dates of items on the emergency trolley.

• Replace, re-stock and re-order items which are found to have passed their expiry date, when undertaking checks of the emergency trolley.

• Document any learning points from significant events or incidents on the recording matrix used by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection of ELM Alliance Limited Extended Hours and Out of Hours service (known as the STAR service) on 11 and 12 July 2017 as we had received some information of concern about the out of hours service being provided. Overall the service is rated as inadequate. We visited two locations that the service is delivered from; Park Surgery in Middlesbrough and Bentley Medical Practice at Redcar.

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

• There was no open and transparent approach to safety and no effective system in place for recording, reporting and learning from significant events.
• Risks to patients were not adequately assessed or acted upon.
• We found concerns about the management of medicines.
• There was a system in place that enabled staff access to patient records, and information was shared with the patients GP following contact with patients using the out of hours service
• The service managed patients’ care and treatment in a timely way with the exception of home visits which were below the national quality requirements.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Safeguarding procedures were not always followed.
• There was a lack of overarching governance.
• There was an ineffective system for handling complaints and complaints handling was not used to improve services within the organisation.
• The vehicle used for home visits was not well equipped and some emergency equipment was not readily available at the sites visited.
• There was a leadership structure but communication between staff and management was limited and some staff felt unsupported by managers.

The areas where the provider must make improvement are:

• Staff recruitment procedures must be implemented and staff must be recruited safely.

• Implement effective safeguarding referral procedures and ensure that all referrals are followed up in a timely way and that this is documented.

• Complaints and incident reports from patients and staff must be appropriately recorded, investigated, responded to and the learning from these must be appropriately disseminated to all staff in order to facilitate a culture of ongoing improvement.

• Clear governance and leadership arrangements must be implemented to ensure that clinical and managerial leaders understand and can mitigate risks to patients and staff and have an effective oversight of the performance of the out-of-hours service at all times.

• There must be documented processes in place for monitoring clinical equipment, to ensure that it is fit for purpose and that disposable items are in date.

• Stock items of medicines must be replenished to ensure that the service can offer appropriate treatment to patients.

• Health and safety policies and procedures must be implemented and bespoke to the location where the service is provided form.

• Fire drills should be carried out and outcomes documented. Fire training for all staff must be kept up to date. There must be an appropriate documented fire risk assessment in place that is bespoke to the out of hours service provided from each location.

• SMART cards (a unique user system for accessing electronic patient records) must only be used by the person whom the SMART card has been issued to and the practice of sharing or using another person’s cards must cease.

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development and supervision to enable them to carry out the duties.

The areas where the service should make improvements are:

• Clinical supervision should be facilitated for all clinicians and this should be recorded. One to one support should be made available to all staff.

• An effective induction programme which includes areas of mandatory training should be implemented.

• Infection control audits, specific to each location must be undertaken and these should include action plans and review dates.

• The provider should implement an effective process to make sure that all staff are kept up to date and informed of key issues taking place at the service.

• Have systems in place to ensure that National Quality Requirement (NQR) key performance indicators are met each month in respect of face to face consultations in patients’ homes.

• Implement an effective system to record staff training and be satisfied that this is accurate and up to date.

• Implement an effective system for the management of controlled drugs, in line with the provider’s Home Office licence.

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 FRCGP Chief Inspector of General Practice