Archived: Primecare - Primary Care - Birmingham

We carried out an announced comprehensive inspection of Primecare – Primarycare – Birmingham on 28 March 2017 and 29 March 2017. The provider received an overall rating of inadequate and was placed into special measures. Following the inspection we issued a notice of proposal to cancel the regulated activities and registered manager at this location in relation to Regulation 17: Good governance. On 17 August 2017 we undertook a focused follow up inspection to confirm the provider was carrying out their plan to meet legal requirements in relation to breaches identified in the notice of proposal. You can read the full reports from the March 2017 and August 2017 inspections, by selecting the 'all reports' link for Primecare – Primary Care – Birmingham on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection, carried out on 17 and 18 January 2018. The purpose of the inspection was to confirm that the provider 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 28 and 29 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection we found the provider had made adequate improvements.

This service is now rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

At this inspection we found:

• The provider had made significant improvements to address the breaches and improve the service delivered since our previous inspection in March 2017. The provider had put in place an action plan and turnaround team to support the local management to deliver the necessary improvements.

• The service had put in place systems to manage risk so that safety incidents were less likely to happen. For example, in relation to the premises, infection control, the management of medicines and safety alerts.

• There were improvements in reporting incidents and we saw evidence of learning being shared across the organisation. However, incident reports seen did not always clearly detail the action taken or which service they related to. Themes and trends were analysed at provider level to identify areas for improvement but did not distinguish between the different locations.

• The service routinely reviewed the effectiveness and appropriateness of the care it provided. Consultation audits were undertaken and areas of concern were followed up. We saw improvements in the sharing of evidence based guidance with clinical staff.

• The provider had improved the reporting of National Quality Requirements and we saw overall improved performance since our previous inspection. Staff told us there were systems for reviewing performance, however no documentation was maintained to demonstrate this and action taken in response to breaches.

• A programme of clinical audits had been identified and findings shared with clinical staff. However, none only one was a full cycle and did not demonstrate improvements made.

• The provider demonstrated effective joint working arrangements with key partners to develop co-ordinated care.

• Feedback collected by the provider and through CQC comment cards indicated that patients were treated with kindness, dignity and respect.

• Since our previous inspection in March 2017 the provider had made improvements to ensure patients received care and treatment from the service within an appropriate timescale for their needs. However, there was scope for further improvements such as the timeliness of less urgent home visits.

• There had been significant improvements in the provider’s governance arrangements. There was clearer leadership arrangements. Staff meetings had been instigated and most staff we spoke to felt valued and respected. However, there were some staff who did not feel well supported.

• The provider demonstrated a commitment to continuous learning and improvement. They had acted on the feedback from our previous inspection and were working closely with the CCG to develop integrated urgent care in the local area.

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

• Ensure effective systems and processes continue to be established to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Develop clear support systems for staff working in isolation during the out-of-hours period including formal opportunities to meet, discuss and raise issues relating to their role.

• Review systems for monitoring compliance against performance targets to support improvements in the timeliness of care and treatment patients received.

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

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection on 27 August 2017 to confirm that the provider 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 28 March 2017 and 29 March 2017.

This inspection was undertaken to follow up on a Notice of Proposal to cancel registration we issued to the provider and the registered manager in relation to:

• Regulation 17: Good governance.

The provider received an overall rating of inadequate following our inspection on 28 March 2017 and 29 March 2017 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the report.

We issued a Notice of Proposal to cancel registration and this report only covers our findings in relation to the areas identified in the Notice of Proposal as inadequate during our inspection in March 2017. You can read the full report from most recent comprehensive inspection during March 2017, by selecting the 'all reports' link for Primecare – Primary Care – Birmingham on our website at www.cqc.org.uk.

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

• The provider had had taken action to address the areas identified in the Notice of Proposal to cancel registration, and had made improvements in relation to each of these.

• The provider had a clear vision and values and staff were aware of and engaged with these.

• There was a clear staff structure which included responsibilities and lines of reporting.

• The provider had implemented a process for responding to nationally-recognised guidance.

• The provider had implemented revised, comprehensive arrangements for keeping patients safe.

• Arrangements were in place for managing risks relating to premises, vehicles and equipment.

• There were suitable processes for managing medicines, including storage, transport, disposal and record keeping.

• The provider demonstrated a comprehensive understanding of their performance and quality.

• Arrangements for responding and acting upon patient and staff feedback had improved.

• The provider demonstrated a focus on continued service improvement.

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 at Primecare – Primary Care – Birmingham on 14 April 2015. The overall rating for the service was requires improvement. The full comprehensive report on the April 2015 inspection can be found by selecting the ‘all reports’ link for Primecare – Primary Care – Birmingham on our website at www.cqc.org.uk.

This inspection was undertaken to follow up progress made by the provider since the inspection on 14 April 2015. It was an announced comprehensive inspection on 28 March 2017 and 29 March 2017. Overall the service is rated inadequate.

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

• There were systems in place for recording incidents however, they did not clearly demonstrate wider learning to ensure service improvement.
• Risks to patients were assessed but were not always well managed. We identified weaknesses in the management of safety alerts; safeguarding arrangements, chaperone arrangements, management of infection control and equipment checks.
• There had been improvements in the management of medicines since our previous inspection however, we identified issues relating to the safe management of controlled drugs and storage of medicines and prescriptions at one of the primary care centres.
• The provider was not consistently meeting the National Quality Requirements (NQR) (performance standards) for GP out of hours services and was unable to clearly demonstrate how it responded to breaches identified. For example reported data showed that patients’ care and treatment was not consistently managed in a timely way. There were also some discrepancies in the NQR reports which made them difficult to understand and unreliable in supporting service improvements.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Consultations were audited and fed back to individual clinicians to support improvement.
• The provider did not have effective systems for sharing best practice guidance.
• There were systems in place for sharing relevant information with other services to support patient care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand and there were effective systems for managing complaints. However, the provider did not proactively undertake local trend analysis of complaints and concerns to support service improvements.
• The provider was working with other organisations involved in the integrated urgent care pathway to help improve the patient experience.
• There was a lack of senior leadership in the running of the service and lack of clear lines of accountability. There were areas of responsibility that were not clearly defined or understood. For example, for addressing breaches in NQRs, health and safety issues within the primary care centres, acting on safety alerts and for following up audits. There was no safeguarding or infection control lead within the organisation. Managers were not always able to answer questions about the service.
• The service sought feedback from staff and patients, but staff could not demonstrate how this was utilised to support improvement.

The areas where the provider must make improvement are:

• Ensure effective systems are in place to assess, monitor and mitigate risks, for example, identifying trends in relation to local incidents and complaints and for sharing of the wider learning to staff to support improvement.
• Ensure effective systems for the management of risks to patients in relation to the safety alerts, safeguarding, chaperoning, infection control, equipment (including emergency equipment), medicines and health and safety of premises used.
• Ensure effective systems for communicating with all staff to ensure they are kept up to date and for disseminating best practice guidance.
• Ensure effective systems are in place to assess, monitor and improve the quality of the services, for example, managing and addressing issues relating to performance such as the national quality requirements, patient feedback and for improving the quality of service for example through completed audit.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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