All inspections: Carnarvon Medical Centre

We carried out a review of the data available to us about Carnarvon Medical Centre 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 Carnarvon Medical Centre, you can give feedback on this service.

We carried out an announced inspection at Carnarvon Medical Centre on 21 July 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 19 November, 2020, the practice was rated Inadequate overall and Inadequate for providing safe services, effective services and well-led services. It was rated Requires Improvement for providing responsive services and Good for providing caring services. The provider was placed in special measures and we took enforcement action and issued a warning notice.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Carnarvon Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to re-rate the practice and to follow up on:

A warning notice served following our last inspection relating to the following:

Leaders could not fully demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements were ineffective and not fully embedded.
The practice did not have effective processes for managing risks, issues and performance.
The practice did not always act on appropriate and accurate information.
The system for complaints and significant events was not effective and therefore learning and service improvement was limited.

Also, to review areas identified at our last inspection where the provider should make improvements:

Increase the percentage of respondents to the GP patient survey who stated that the last time they had a general practice appointment, the healthcare professional was good or very good at listening to them.
Improve the number of patients on its register who are identified as carers.
Update the information regarding data protection on the website to include online consultations.
Ensure child pads are available for use with the defibrillator.
Improve the monitoring of fridge temperatures used to store vaccines.
Improve the recording of action taken as a result of patient safety alerts.
Ensure all staff are supported to recognise the acutely unwell patient, including signs of sepsis.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

Conducting staff interviews using video conferencing
Completing clinical searches on the practice’s patient records system and discussing findings with the provider
Reviewing patient records to identify issues and clarify actions taken by the provider
Requesting evidence from the provider
A short site visit

Our findings

We based our judgement of the quality of care at this service 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 Good overall and Good for all population groups, except Working Age People, (including those recently retired and students), which we have rated as Requires Improvement.

We rated the population group, Working Age People, (including those recently retired and students), as Requires Improvement because we found that the performance for the uptake of three cancer screening indicators remained lower than the local and national averages.

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

Continue to monitor and audit the number of prescription items for antibiotics to bring the prescribing in line with local and national averages.
Include the outcome of shared cared monitoring on the patient record.
Continue to improve the take-up of childhood immunisations and undertake regular reviews of performance realting to cancer indicators and update the action plans where appropriate.
Monitor the percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months, to improve performance in line with local and national averages.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Carnarvon Medical Centre on 12, 13 and 19 November 2020. We rated this service as Inadequate overall.

This inspection was to follow up on a warning notice for breaches of Regulation 12, Safe Care and Treatment and Regulation 17, Good Governance which had been issued to the practice following a previous inspection in October 2019.

The previous inspection history is as follows:

We inspected this practice in November 2018 and we rated them as requires improvement overall, requires improvement for providing safe care and treatment, requires improvement for providing effective care and treatment, good for providing caring, responsive and well-led care and treatment.

We inspected this practice in October 2019 and we rated them as requires improvement overall, inadequate for providing safe care and treatment, requires improvement for providing effective and well-led services and good for providing caring and responsive services. The practice was issued with a warning notice for improvement.

We had scheduled an inspection to follow up on the warning notice earlier this year, but this was cancelled due to the COVID-19 pandemic. Therefore, we followed up on the warning notice at this inspection. Whilst the provider had met most of the requirements of the warning notice, new concerns were identified during the inspection.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews and reviewed documents sent by the provider from 12 November 2020 and carried out a site visit on 19 November 2020.

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information the practice sent to us prior to the inspection
information from our ongoing monitoring of data about services and
information from the provider and other organisations.

We have rated this practice as inadequate overall.

We rated the practice inadequate for providing safe services because:

There were no regular multi-disciplinary meetings held with other health professionals. This had not changed since the previous inspection.
Although we saw posters on display which described the signs and symptoms of sepsis, clinical staff and reception / administration staff we spoke to could not clearly describe the signs and symptoms.
There was no evidence of patient care plans on the system.
On the day of inspection, we found that prescription stationery was not kept securely, and its use was not monitored in line with national guidance.
Vaccines were not appropriately stored, in line with PHE guidance to ensure they remained safe and effective.
There were no child pads for use with the defibrillator.
Some anti-bacterial prescribing remained high and required improvement.
The practice did not have appropriate systems in place for the safe management of medicines. Where reviews of high-risk medicines had been undertaken, they were not recorded consistently in the patient’s record.
The practice did not learn and make improvements when things went wrong. Significant events were not being reviewed effectively to identify learning. This had not improved since the last inspection.

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

Childhood immunisation uptake and cancer performance indicators continued to be below the national minimum targets and this had not been actioned from previous inspections.
There was no programme of quality improvement and information wasn’t always used to make improvements about care and treatment.

We have rated the population groups, families children and young people and working age people as inadequate as both of these isues affected these population groups.

We have rated the remaining population groups as requires improvement due to the lack of a programme of quality improvement, including clinical audit.

We have rated this practice as inadequate for providing well-led services because:

Leaders could not fully demonstrate that they had the capacity and skills to deliver high quality, sustainable care. While the practice had a vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements were ineffective and not fully embedded. While some improvements had been made since our last inspection, there were some repeat and new issues found at this inspection.
The practice did not have effective processes for managing risks, issues and performance.
The practice did not always act on appropriate and accurate information.

The system for complaints and significant events was not effective and therefore learning and service improvement was limited.We have rated this practice as requires improvement for providing responsive services because:

Complaints were not always acknowledged in a timely manner and investigations did not always fully identify areas for service improvement and development.

This area affected all population groups so we rated all population groups as requires improvement.

We rated this practice as good for caring because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Increase the percentage of respondents to the GP patient survey who stated that the last time they had a general practice appointment, the healthcare professional was good or very good at listening to them.
Improve the number of patients on its register who are identified as carers.
Update the information regarding data protection on the website to include online consultations.
Ensure child pads are available for use with the defibrillator.
Improve the monitoring of fridge temperatures used to store vaccines.
Improve the recording of action taken as a result of patient safety alerts.
Ensure all staff are supported to recognise the acutely unwell patient, including signs of sepsis.

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 groups, 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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Carnarvon Medical Centre on 14 October 2019 as part of our inspection programme.

At this inspection, we followed up on breaches of regulations identified at a previous inspection on 20 November 2018, when we rated the practice as requires improvement overall. Specifically, we rated safe and effective as requires improvement with caring, responsive and well-led rated as good.

We found that not all of the areas of concern at the previous inspection had been adequately addressed, specifically:

Not all staff had received a disclosure and barring system (DBS) check, including some staff who had completed chaperone training. The practice had not provided a clear rationale or carried out risk assessments for their decisions regarding which staff were required to have a DBS check.
The number of patients who identified as carers had not increased.
The uptake for cervical screening and childhood immunisations had not improved.

We based our judgement of the quality of care at this service 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 requires improvement overall.

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

Not all staff had received a disclosure and barring system (DBS) check, including some staff who had completed chaperone training. This is a repeat issue from the previous inspection.
There was no child or adult safeguarding policy in place which was specific to the practice.
There was no recruitment policy and procedure in place and staff files were inconsistent. Staff vaccination was not maintained in line with current Public Health England (PHE) guidance.
Health and safety checks of the premises were unclear, and records were incomplete.
Reviews following a complaint or significant event did not ensure that measures were put in place to reduce the likelihood of recurrence.
There was no formal induction for new staff.
Not all staff had received training on infection prevention and control.

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

Training records were incomplete and there was no oversight or monitoring. For example, records did not assure us that all staff had attended infection control training or appropriate safeguarding training. This impacted on all of the population groups.
The performance indicators for patients with diabetes showed negative performance over time, with no plan in place for improvement.
The data for two of the childhood immunisation indicators were below target for the year 2018/2019 and were also below target for the previous year 2017/2018, with no plan in place for improvement.
The performance data for cancer indicators was below national averages for all five indicators and was below both local and national averages for four out of the five indicators.
The data for cervical screening was also below local and national averages for 2018/19 and for the previous year, 2017/2018.

We rated the practice as requires improvement for providing well-led services because:

There was a lack of effective systems in place to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity.
There was a lack of effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.

The areas where the provider must make improvements are:

Ensure 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.
Improve the outcomes for patients in all of the population groups.
Review performance around inadequate cancer screening results and consider how to improve uptake.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Develop an effective system for the monitoring of complaints, including dissemination of learning.
Improve the identification of patients who are carers.
Continue to monitor and review the level of antibacterial prescribing.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as Requires Improvement overall. This is the first inspection for this practice.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Carnarvon Medical Centre on 20 November 2018 as part of our inspection programme.

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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
The practice involved patients in regular reviews of their medicines.
There was an effective system for receiving and actioning safety alerts.
We found the practice had appropriate systems in place to monitor medicines requiring refrigeration.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Staff had received training applicable to their role and the practice provided staff with ongoing support.
We found the practice had conducted environmental risk assessments and completed actions identified.
The practice had identified 0.78% of its practice list as carers by highlighting them during registration and clinical consultations.
The practice was clean and tidy and staff had reviewed infection prevention control and policies.
Data from the national GP patient survey published in July 2018 showed patients rated the practice in line with local and national averages for all aspects of care.
We received 20 positive comment cards regarding the care and service at the practice and seven mixed reviews.
The outcome data for people with long term conditions was lower than local and national averages.
The uptake for cervical screening and child immunisations was lower than local and national averages.
They had found it difficult to sustain a patient participation group.
The practice had carried out a low number of clinical and non-clinical audits.
There was no appraisal system in place for staff.
Staff with chaperone responsibilities did not have a Disclosure and Barring Service (DBS) check and there were no risk assessments in place to mitigate any risk associated with this decision.

The areas where the provider must make improvements are:

Ensure 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

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

The areas where the provider should make improvements are:

Continue to actively encourage patients to join the patient’s participation group. meet regularly.
Increase the number of patients who are carers identified and provide them with appropriate support.
Work towards improving patient uptake for cervical screening and childhood immunisations.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Carnarvon Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

21July 2021

During a routine inspection

19 November 2020

During a routine inspection

14 Oct

During a routine inspection

20 Nov - 20 Nov

During a routine inspection