Castletown Medical Centre

We carried out an announced inspection at Castletown Medical Centre on 11 May 2021. Overall, the practice is rated as inadequate;

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Inadequate

Well-led - Inadequate

We previously inspected the practice on 5 January 2016, the practice was rated good overall and for effective, caring, responsive and well-led services. The practice were rated requires improvement for providing safe services. Following a further inspection on 15 August 2016, the practice was rated Good overall and for the key question of safe.

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

Why we carried out this inspection

This inspection was a comprehensive inspection, we have carried out this inspection because we received information of concern relating to insufficient clinical presence at the practice, limited numbers of administration staff suggesting that the practice was neither safe or accessible to patients.

How we carried out the inspection/review

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, on the telephone and face to face
• 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 inadequate overall and inadequate for all population groups.

The population groups are rated inadequate overall because there are aspects of the practice that are inadequate which therefore has an impact on all population groups.

We rated the practice as inadequate for providing safe, effective, responsive and well led services because:

• There were not enough members of staff working at the practice to keep patients safe who were fully trained and in the correct role, with clear accountabilities.
• Due to the limited experience of the staff in administrative roles and lack of access to information, we were concerned that staff could not identify and respond to the changing risks to patients who used the service, including deteriorating health and well-being or medical emergencies.
• There was no overall training, the practice were not recording and monitoring staff training to ensure staff had the skills and experience needed to carry out their roles. There was no evidence of staff receiving appraisals.
• In the clinical notes of four out of five hypertensive patients we looked at we saw that they had been monitored by a non-medical prescribing nurse without the clinical oversight of the GP.
• There was no clear evidence of effective monitoring for high risk medication. Advice from the medicines and healthcare products regulatory agency (MHRA) was not being followed.
• The practice did not have a system for the management of patient and drug safety alerts and therefore could not ensure medicines were prescribed safely.
• Some patients had not had a structured and comprehensive medication review.
• The lack of some systems and processes meant that patient’s needs were not always identified. For example, there were examples of poor-quality and inaccurate coding of patient records.
• The practice did not have a system in place to learn and make improvements when things went wrong. There was no clear process for the recording of significant events, some staff we spoke with told us they were fearful of raising significant events and they were not allowed to enter them on the local risk and incident reporting system.
• We found care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance
• A review of the mental health register found four patients had not been formally reviewed and they did not have a documented care plan in place.
• We were concerned that the arrangement for appointments at the practice was unreasonable and unsuitable and left patients at risk of not receiving timely access to appointments.
• Patients were not encouraged to put their concerns or complaints in writing. The practice thereby lost any opportunity to learn from these concerns or rectify what had happened for patients.
• We found a lack of leadership capacity and capability to successfully manage challenges and implement and sustain improvements.
• The practice could not evidence that some risks, issues and performance were managed to ensure that services were safe or that the quality of those services was effectively managed.
• We were concerned that there was a blame culture in the practice, some staff were fearful of raising concerns and received a lack of support from management.
• We found a lack of governance and assurance structures and systems which led to serious patient safety concerns identified at this inspection.

We rated the practice as good for providing a caring service because:

• National GP survey results were positive.
• The practice received good feedback from the NHS friends and families test.
• The practice had identified carers at the practice.

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

• Ensure care and treatment is provided in a safe way to patients
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment

This is in accordance with the fundamental standards of care.

We are currently in the process of undertaking enforcement action against this provider. Once the appeal process has been concluded we will publish a supplementary report detailing the actions taken.

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.

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