Lessons from CQC inspections

What can we learn from the first results of the more robust Care Quality Commission (CQC) inspections of GP practices that got underway in October 2014?

It is the Care Quality Commission’s intention to give every GP practice in England an ‘Ofsted-style’ rating on a four point scale – ‘Outstanding’, ‘Good’, ‘Requires improvement’ or ‘Inadequate’ – so that members of the public can see at a glance how their local surgery is performing. And from April, practices will have to display their ratings.

Following the first rounds of these new inspections, the CQC has now published details of 142 practices: of these, six have been outstanding, 112 have been good, 20 have been judged to require improvement and five have been ruled inadequate. Three of these have been placed in special measures, and two other practices have been told there are areas that they must improve.

WHAT DOES OUTSTANDING LOOK LIKE?

All practices that were rated as outstanding had gone above and beyond to reach out to their communities to meet particular local needs.

Imperial Road Surgery, Matlock

The report on the Imperial Road surgery in Matlock, Derbyshire,1 highlights a number of areas of outstanding practice, including:

• The practice provides medical support to a local drug misuse service, and is helping to change perceptions about people who have a drug dependency. The practice works pro-actively with relevant services, which has enhanced their safeguarding links and ensures a holistic approach to supporting families and patients who have a drug dependency.
• Effective leadership enables staff to drive continuous improvements and implement innovative ways to meet patients’ needs. For example, the community matron regularly visits patients in their own homes or care homes, and holds quarterly management meetings to review their needs.
• The Patient Reference Group is actively involved in recruiting senior staff including the current practice manager.
• The practice has links with local schools and has provided several presentations to pupils about health issues. Pupils from a local school designed the new logo for the practice.

Radbrook Green Surgery, Shrewsbury

The report on Radbrook Green Surgery,2 Shrewsbury, Shropshire also highlights a number of areas of outstanding practice, including:

• The practice uses a nationally recognised patient safety framework to enable them to identify and put plans of care in place for patients with the highest health risks.
• A community and care coordinator is employed to provide services to support vulnerable people. This included a support group for carers of people with dementia and a twice-monthly bereavement support group.
• The practice proactively engages with teenagers to involve them in health care services.
• A support group for patients with chronic fatigue and Myalgia Encephalopathy (ME) has been established to ensure patients are supported in decisions about available care and treatment.
• The practice helped to establish Compassionate Communities, a voluntary service the community, and works with a care coordinator to provide support vulnerable patients.
• The practice provides GP support to a 12 bed rehabilitation unit in a nursing home for patients whose vulnerability means they need additional support following discharge from hospital.

The CQC concluded that the Radbrook Green Surgery is providing an effective and well led service which is a real asset to the people living in this part of Shropshire. The practice displayed an excellent understanding of the differing needs of their patients with the community of Shrewsbury and acted on these needs in the planning and delivery of its services.

St Thomas Health Centre, Exeter

The St Thomas Health Centre in Exeter, Devon was also rated outstanding.³

The practice is responsive to the needs of patients and provides services even when the service provided was not included in the GP contract. For example:

• The practice nurses and health care assistants perform complex leg ulcer dressings in the practice following extended training at the local hospital with community nurses who had extended training in tissue viability. The practice nurses have also worked with the dermatology department at the local acute trust to obtain training and advice. St Thomas staff input meant patients were able to receive this complex treatment at the practice avoiding the need to attend the community leg ulcer clinic on the other side of the city. This service was over and above what was expected from the practice in the GP contract and has improved outcomes for patients.
• An additional service is provided by staff at the practice for patients with indwelling intravenous lines used for prolonged treatments, for example, chemotherapy, long term antibiotics and intravenous feeding. Under normal circumstances, patients would be required to go to hospital for management of intravenous lines, but at this practice, staff completed extended training to enable patients to receive care locally, at the surgery.
• Staff at the practice and the Friends of St Thomas Health Centre raised money to fund equipment, transport and maintenance of a pain-relieving gas for complex wound dressings. The practice has also facilitated extended staff training to enable patients to stay at home and be treated at the practice and in the community rather than remaining in hospital for complex wound care.
• In addition, the practice has responded by making sure information was provided to help patients with learning disabilities understand the care available to them. For example, administration staff had recognised the literature given out regarding the practice and health checks was inadequate and had changed the documents to easy read versions for these patients.
• The practice has a very active carers support group, a group of volunteers co-ordinated by a member of the practice team, which offers services to all patients, but especially to isolated and lonely patients.

All practices employ a range of skill mix which includes nurse practitioners, practice nurses and healthcare assistants and have a commitment to education and training in place with a culture of further education to benefit patient care and increase the scope of practice for staff.

WHAT DOES INADEQUATE LOOK LIKE?

Professor Nigel Sparrow, CQC’s Senior National GP Advisor said: ‘It is disappointing that we have found any to be “inadequate”, but it is important that those practices are offered help at the earliest opportunity to improve.

‘In each case, we have found significant areas of concern. Patients should be able to expect high quality and consistent care from their GP, which is why I have put the three practices into special measures. Two practices have already begun to show signs of improvement but we will monitor their progress closely, returning to inspect in the near future.’

The practices where the CQC uncovered significant concerns are in Liverpool, Reading and Greater Manchester.

• A practice in Liverpool was rated inadequate against all five of its inspection metrics (safe, effective, caring, responsive and well-led).
• A practice in Greater Manchester was rated inadequate against two of the five questions (safe and well-led), and rated as ‘requiring improvement’ against the metrics of ‘responsive to people’s needs’ and ‘effective’.
• A practice in Reading, Berkshire was rated inadequate for three questions – safe, effective and well-led, and requiring improvement against the criteria caring and responsive.

All three practices have been placed in ‘special measures’ and have been given six months in which to dramatically overhaul how they operate or face being closed. Special measures mean they will be put under strict supervision and offered a package of help to improve coordinated by NHS England and the Royal College of GPs.

The practice in Reading has been told to make improvements in 14 areas after a visit by inspectors in November.⁴

The practice must take immediate action to address current staffing issues to ensure safe minimum levels are reached.

• Clinical leadership and management must be provided for all staff.
• The practice must develop and implement a system to regularly identify risks and improve quality in relation to patient safety.
• All patients’ records must be updated with appropriate information and documents in relation to the care and treatment they have received.
• Regular infection control audits must be undertaken, and a cleaning schedule introduced for practice equipment.

The Greater Manchester practice5 has been given several areas in which it has to improve after an inspection last October, preceded by other visits which gave inspectors concerns about potential threats to patients’ safety and welfare.

• The practice is rated as inadequate for safe services and improvements are required.
• There were safeguarding procedures in place and staff had received training in safeguarding children and vulnerable adults. However, there were no systems in place to review and monitor patients who may be at risk or vulnerable within the practice population.
• Medicines management processes were ineffective and policies and procedures were not followed.
• There were policies available to staff detailing how to deal with foreseeable emergencies but staff were not familiar with these and told us they used common sense to deal with situations.
• Infection control and prevention policies were not specific to the practice. Following an audit by the local NHS trust in August 2014, actions recommended had still not been completed.
• There was no effective system in place to investigate and learn from incidents that occurred at the practice.

The Liverpool practice6 was rated as inadequate in terms of how safe, effective, well-led, caring and responsive it was – the five key questions the CQC uses to judge health service providers’ performance.

The CQC identified 10 areas for improvement, including:

• The practice must take action to protect patients from the risks of inappropriate or unsafe care and treatment by implementing a system to regularly assess and monitor the quality and safety of the service.
• The practice must ensure alerts about potential issues with medicines and equipment are shared with all staff so that changes to the treatment of patients can be undertaken swiftly if necessary.
• The practice must take action to protect patients by ensuring suitable arrangements are in place to share information with other healthcare professionals when they move between services.
• The practice must ensure that suitable arrangements are in place so that all staff respond appropriately to any safeguarding concern.
• The practice must ensure necessary employment checks are in place for all staff.

Like the other two, the practice needs to go into special measures to work out how to solve their problems by receiving external help. That could involve extra staff arriving, new management at the practice or it being partnered with a high-performing surgery.

Dr Mike Bewick, Deputy Medical Director, NHS England, said: ‘General practice is the bedrock of the NHS and it’s pleasing that the majority of practices inspected are rated good, with some rated outstanding. These inspections are about ensuring that every patient, anywhere across the country, receives consistently high quality services by identifying issues so improvements can be made. And for those in special measures that need extra support, we are working with the GPs, Local Medical Committees and CCGs to help turn the affected practices around, including the offer of additional support from the RCGP.’

Professor Sparrow said: ‘We will only cancel the registration of a GP practice if we think it is absolutely necessary – and in any case our priority will be to help the practice improve, if that is appropriate. In these situations we will work closely with NHS England who will ensure that people registered at that practice continue to have access to safe and high quality general practice.’

REFERENCES

1. CQC report on outstanding practice in Matlock, Debyshire http://www.cqc.org.uk/content/derbyshire-gp-surgery-rated-outstanding-care-quality-commission

2. CQC report on outstanding practice in Shrewsbury, Shropshire http://www.cqc.org.uk/content/shropshire-gp-surgery-rated-outstanding-care-quality-commission

3. CQC report on outstanding practice in Exeter, Devon practice http://www.cqc.org.uk/content/st-thomas-health-centre-rated-outstanding-care-quality-commission

4. CQC report on inadequate Reading, Berkshire practice http://www.cqc.org.uk/location/1-715881521

5. CQC report on inadequate Liverpool practice http://www.cqc.org.uk/location/1-487357498

6. CQC report on inadequate Greater Manchester practice http://www.cqc.org.uk/location/1-517818696