We carried out a review of the data available to us about LPS - Weatheroak Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about LPS - Weatheroak Medical Practice, you can give feedback on this service.
We previously carried out an announced comprehensive inspection at LPS Weatheroak Medical Practice on 17 October and 1 November 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the inspection carried out on 17 October and 1 November 2016 was published on 25 January 2017, and can be found by selecting the ‘all reports’ link for LPS Weatheroak Medical Practice on our website at www.cqc.org.uk.
On 5 July 2017 we carried out an announced, follow-up comprehensive inspection to confirm the practice 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 17 October and 1 November 2016. This report covers our findings in relation to those requirements.
We found the practice had carried out detailed analysis of the previous inspection findings, and had then sought support from and involved stakeholders including the Clinical Commissioning Group (CCG) and Patient Participation Group (PPG). The practice had then made extensive changes which had resulted in significant improvements. Practice staff had taken responsibility for embedding and maintaining these improvements themselves. There was evidence of a cultural and leadership change within the practice, and we saw a positive approach to performance and improvement throughout.
Our key findings were as follows:
People were protected by a strong, comprehensive safety system and a focus on openness, transparency and learning when things went wrong.
The practice had clearly defined and embedded systems to minimise risks to patient safety.
Arrangements for managing medicines kept patients safe.
Staff were aware of current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment, including regular training updates.
Patient outcomes were above local and national averages.
The practice had appropriate arrangements to identify patients who were carers to enable them to receive care, treatment and support that meets their needs.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Patients’ satisfaction with how they could access care and treatment was in line with or above local and national averages.
Information about services and how to complain was available in a range of languages. Improvements were made to the quality of care as a result of complaints, concerns and patient feedback.
There was effective oversight, planning and responses to practice performance.
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 is now rated as good for providing safe services, for providing effective services, for providing caring services, for providing responsive services, and for being well-led. The overall rating for the practice is now good.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at LPS-Weatheroak Medical practice. Overall the practice is rated as Inadequate.
Our key findings were as follows:
Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was no formalised process in place for receiving and responding to medicine and safety alerts.
There was no systematic approach to national and local clinical guidance in place.
The arrangements for managing medicines in the practice did not always keep patients safe. For example, the practice nurse was administering medicines, such as vaccines, without Patient Group Directions in place on 17 October. However, the practice took action on this immediately following the inspection.
Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, the arrangements for managing high risk medicines were not always effective.
No learning disability patients were recalled for annual health checks in 2015/16.
Not all staff were up to date with mandatory training, for example annual basic life support was completed in March 2015. However following our inspection this was to take place 2 November 2016. The practice nurse had not completed training in the Mental Capacity Act, information governance, infection control or fire safety training at the practice.
Patient records were not always managed in a secure way in that computer system smart cards were left unattended in clinical rooms. The keypad operated door to the first floor was found unlocked and patient paper records were held in an unlocked room and not housed in metal cabinets. Subsequent to the inspection the provider fitted a lock to the second floor records room.
Patients spoken with were positive about their interactions with staff and said they were treated with compassion and dignity.
Practice staff had good local knowledge about their local patient population and spoke several languages.
There was continuity of care and urgent appointments were available the same day.
There were areas of practice where the provider needs to make improvements.
Ensure that care and treatment is provided in a safe way for service users. The provider must put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines and ensure guidelines are implemented.
Ensure all clinical and non-clinical incidents and ‘near misses’ that may affect the health, safety and welfare of people using services are reported, recorded and investigated.
Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
The practice must ensure that internal procedures for responding to nationally recognised guidance for delivering safe care and treatment; including patient safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) are followed and documented through to full completion.
Ensure the proper and safe management of medicines. Ensure there is an effective repeat prescribing policy, system and protocol in place for the recall and review of patients; particularly those who are on medicines which require close monitoring. Ensure there are appropriate arrangements in place for managing Patient Group Directions (PGDs).
Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely. Ensure systems are in place to keep all staff up to date with role specific training, including training in annual basic life support, and that appropriate records are kept.
Ensure the complaints policy and procedures are in line with recognised guidance and contractual obligations for GPs in England.
Implement patient information literature which is in formats suitable for the patient group.
Review systems to improve the identification of carers in order that the practice may provide appropriate support.
Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.
Chief Inspector of General Practice