Archived: 3Well Ltd - Botolph Bridge Also known as 3Well Medical

Letter from the Chief Inspector of General Practice

This was the sixth inspection that we have carried out at 3Well Ltd – Botolph Bridge.

We carried out a comprehensive inspection of 3Well Ltd - Botolph Bridge on 7 May 2015. The practice was rated as good overall with ratings of good for providing safe, caring, and responsive and well led services, and requires improvement for effective services. As a result of the findings on the day of the inspection, the practice was issued with a requirement notice for regulation 17 (good governance).

We carried out a second comprehensive inspection on 10 June 2016. This inspection was in response to concerns raised by members of the public and to check if the practice had made the changes required from the inspection in May 2015. The practice was rated as inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services.

At our June 2016 inspection we found that some of the improvements needed as identified in the report of May 2015 had been made, however, some of these needed to be improved further. Patients were at risk of harm because systems and processes were not in place to keep them safe. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others. As a result of the findings on the day of the inspection, the practice was issued with a warning notice for regulation 12 (safe care and treatment) and requirement notice for regulation 17 (governance and quality assurance). The practice was placed into special measures for six months.

We conducted a focused inspection on 19 August 2016 to ensure that the practice had made the required improvements detailed in the warning notice that had been issued on 8 August 2016.

At our 19 August 2016 inspection we found that some of the improvements needed as identified in the report of June 2016 had been made, however, some of these needed to be improved further. We further identified a new issue relating to the safe prescribing and management of medicines and we were concerned that patients were at risk of harm. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (19 August 2016) we took urgent action to suspend 3Well Ltd Botolph Bridge from providing general medical services at 3Well Ltd Botolph Bridge.

We conducted a focused inspection on 14 November 2016 to check whether the provider had made sufficient improvements and to decide whether the suspension period should end.

At our 14 November 2016 inspection we found that improvements had been made. We saw that a governance framework had been put in place and that medicines were authorised by GPs and nurses with a prescribing qualification. The practice had prioritised patients and had started a process of reviewing patients identified as ‘may be at risk’ from inappropriate reviews. We found that GPs and nurse practitioners managed pathology results and these had been managed in a timely way. The systems and processes in place to ensure good governance had improved but further improvements were needed to enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (14 November 2016) we decided the suspension should end; however, we imposed urgent conditions on the registration of this provider. The ratings remained the same; inadequate overall and the special measures period continued.

We carried out a comprehensive inspection on 13 February 2017. This inspection was undertaken following a period of special measures. The practice was rated requires improvement overall and for providing safe, effective, and responsive services, inadequate for providing well-led services and good for providing caring services. The practice remained in special measures.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection on 27 October 2017. Overall the practice is now rated as requires improvement. The practice is no longer in special measures.

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

• Throughout the two periods of special measures, the practice was receiving support from the Royal College of General Practitioners team which consisted of a GP, and an advance nurse practitioner.
• Since our last inspection all the practice nurses had left and had been replaced.
• The practice had not been successful in recruiting further principal GPs or salaried GPs; however, they had continued to engage regular locum GPs and had been successful in employing nursing staff, clinical pharmacists, and additional management staff. Due to the shortage of permanent GPs, there was still limited clinical leadership in place.
• We found that improvements had been made to the systems and processes to ensure management and clinical oversight.
• The clinical and management team had regular meetings to manage the performance of the practice in relation to the quality and outcomes framework. The practice overall performance for the Quality and Outcomes Framework (QOF) in 2016/17 was 87% compared to 96% in 2015/16. The exception reporting rate for 2016/17 had significantly reduced from 18% in the previous year to 5%.
• Results from the National GP Patient Survey published in July 2017 showed the practice performance had improved from results published in July 2016 in 12 areas but had remained the same or was lower in eight areas.
• The practice had been working closely with the CCG and was actively working on pilot projects in the area. The practice had engaged with the local network and was able to book appointments for patients at the local GP Hub.
• There was a system for recording significant events and complaints; these were discussed at various meetings and actions taken.
• There was a system in place to ensure regular monitoring of quality and performance and that actions required from hospital correspondence and test results were completed in a timely way.
• The practice evidenced that there were systems in place to provide clinical oversight of all staff that provide care to patients at the practice.
• We saw practice protocols and policies were in place and had been updated to reflect the change in clinical leads. However, not all staff found them easy to access.
• The practice held meetings and encouraged locum clinicians to attend, the practice had introduced and showed evidence that virtual meetings held by email were effective. Staff we spoke with told us they found these useful.
• Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines including childhood immunisations.
• The management of medicines had been further improved. The GPs, pharmacists, or nurses who had prescribing qualifications undertook all medicines changes and reviews, including reconciliation of those that had recently been discharged from hospital. We found all patients on high risk medicines had been appropriately monitored.
• The practice had systems and process in place to record and action safety alerts and these had been well managed.
• The practice stored prescription stationery securely and had a system in place for tracking its use.
• The practice used a programme of audits and searches of medical records to monitor and encourage quality improvement.
• The practice proactively promoted the national cancer screening programmes to encourage uptake.
• A staff member had taken a lead role as a carer’s champion. This staff member contacted any new carer identified to ensure they were aware of the support that was available to them. The practice had raised the awareness of dementia and had information in several languages available. In addition to a translation service, the practice had staff members who spoke other languages, for example Lithuanian, Polish and German.
• The practice had engaged the patient participation group to identify and encourage improvement.

There are areas where the provider should make improvements.

• Continue to build on clinical leadership and active recruitment.
• Continue to implement and monitor the systems and process to ensure that patients receive appropriate follow ups in a timely manner.
• Continue to monitor the GP patient survey data and respond to the results appropriately.
• Review and improve the systems and ensure that staff can access the documents including policies and procedures easily.
• Continue to identify carers to ensure that they receive appropriate support and care.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This was the fifth inspection that we have carried out at 3Well Ltd – Botolph Bridge.

We carried out a comprehensive inspection of 3Well Ltd - Botolph Bridge on 7 May 2015. The practice was rated as good overall with ratings of good for providing safe, caring, and responsive and well led services, and requires improvement for effective services. As a result of the findings on the day of the inspection, the practice was issued with a requirement notice for regulation 17 (Good governance).

We carried out a second comprehensive inspection on 10 June 2016. This inspection was in response to concerns raised by members of the public and to check if the practice had made the changes required from the inspection in May 2015. The practice was rated inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services.

At our June 2016 inspection we found that some of the improvements needed as identified in the report of May 2015 had been made, however, some of these needed to be improved further. Patients were at risk of harm because systems and processes were not in place to keep them safe. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others. As a result of the findings on the day of the inspection, the practice was issued with a warning notice for regulation 12 (Safe care and treatment) and requirement notice for regulation 17 (governance and quality assurance). The practice was placed into special measures for six months.

We conducted a focused inspection on 19 August 2016 to ensure that the practice had made the required improvements detailed in the warning notice that had been issued on 8 August 2016.

At our 19 August 2016 inspection we found that some of the improvements needed as identified in the report of June 2016 had been made, however, some of these needed to be improved further. We further identified a new issue relating to the safe prescribing and management of medicines and we were concerned that patients were at risk of harm. The systems and processes in place to ensure good governance were ineffective and did not enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (19 August 2016) we took urgent action to suspend 3Well Ltd Botolph Bridge from providing general medical services at 3Well Ltd Botolph Bridge.

We conducted a focused inspection on 14 November 2016 to check whether the provider had made sufficient improvements and to decide whether the suspension period should be ended.

At our 14 November 2016 we found that improvements had been made. We saw that a governance framework had been put in place and that medicines were authorised by GPs and nurses with a prescribing qualification. The practice had prioritised patients and had started a process of reviewing patients identified as ‘may be at risk’ from inappropriate reviews. We found that GPs and nurse practitioners managed pathology results and these had been managed in a timely way. The systems and processes in place to ensure good governance had improved but further improvements were needed to enable the provider to assess and monitor the quality of the services and identify, assess and mitigate against risks to people using services and others.

As a result of our focused inspection (14 November 2016) we decided the suspension should be ended but we imposed urgent conditions on the registration of this provider. The ratings remained the same; inadequate overall and the special measures period continued.

This report covers our findings in relation to our focused inspection on 13 February 2017. You can read our findings from our last inspections by selecting the ‘all reports’ link for 3Well Ltd Botolph Bridge on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 13 February 2017. Overall the practice is now rated as requires improvement.

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

• During part of the special measures period the principal GP had been unable to provide clinical services. The practice had employed a clinical lead GP and additional support from a practice manager. Throughout the special measures period, the practice were receiving support from the Royal College of General Practitioners team which consisted of a GP, advance nurse practitioner and a practice manager.

• On the day of inspection the practice told us that they had successfully recruited a salaried GP but they had not yet signed a contract. They had engaged locum GPs and advance nurse practitioners who provided sessions on a regular basis.

• We found that improvements had been made but there were some areas where further improvement was required. Governance systems had improved but the practice needed additional time to review, strengthen, and embed their new process to ensure that the improvements could be sustained over time.

• At our inspection in June 2016, we identified that there was not an open culture to report all incidents of potential sub-optimal care. During our inspection in February 2017 we found that not all staff members felt supported to raise concerns about patient safety. There was a system for recording significant events and complaints; these were discussed at various meetings and actions taken. However, we found that not all cases identified had been recorded as significant events and discussions had not been recorded. Those that had been recorded had been appropriately managed.

• We saw practice protocols and policies were in place and had been updated to reflect the change in clinical leads.

• We saw the practice held meetings and encouraged locum clinicians to attend, some we spoke with told us they did not attend these meetings, nor did they have much involvement in multi-disciplinary team working including end of life care.

• The practice was reliant on locum GPs and advance nurse practitioners to provide appointments for patients. The system to provide clinical supervision for clinical staff needed to be improved. The practice had reviewed some consultations of locum GPs and advance nurse practitioners, but some staff we spoke with told us they had not been engaged in the process and were unaware of any sampling of their consultations or any identified learning. They were not aware of any audits relating to their prescribing practice.

• Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines including as childhood immunisations.We saw that some of the PGD documents were out of date and had not been replaced by the updated versions available from NHS England. This meant the nurses did not have the required legal authorisation to administer the relevant vaccines which are Prescription Only Medicines. The practice took immediate action and obtained the correct versions.

• The management of medicines had been improved. GPs or nurses who had prescribing qualifications undertook all medicines changes and reviews. We found that most patients on high risk medicines had been appropriately monitored. The practice had engaged with the pharmacy situated next door to the practice to further improve communication and safe working practices.

• We saw that the practice had systems and process in place to record and action safety alerts and these had been well managed.

• The practice did not store securely, or have a system in place for tracking the use of prescription stationery throughout the practice.

• Since our last inspection, the practice manager had engaged with the NHS property management team to ensure that the premises were safe and that all checks were completed as required. This included cleaning schedules and the management of legionella disease.

• The practice had a programme of audits and searches of medical records to monitor and encourage improvements but they had failed to undertake audits to monitor the quality of the management of hospital correspondence. This had been identified as an area of improvement required in our May 2015 and June 2016 inspections.

• The clinical and management team had regular meetings to manage the performance of the practice in relation to the quality and outcome framework. The exception reporting rate was 18% which was 7% above the CCG average and 8% above the national average. This was an improvement from our June 2016 inspection where data showed the practice exception reporting was 31% which was 21% above the CCG and 22% above the national average.

• A staff member had taken a lead role as a carer’s champion. This staff member contacted any new carer identified to ensure they were aware of the support that was available to them . The practice had raised the awareness of dementia and had information in several languages available. In addition to translation service, the practice had staff members who spoke other languages, for example Lithuanian, Polish and German.

• The practice had engaged the patient participation group to identify and encourage improvement. The practice had an active on line membership and members met with the practice on a regular basis. In 2015 the group received a commendation award from the national association of patient participation.

The areas where the provider must make improvements are:

• Ensure there is an open culture for all staff to be supported to raise any concerns. The practice must ensure that complete records are held including investigation, actions taken and learning shared from the events.

• Ensure that there is regular monitoring of quality and performance to ensure that actions required from hospital correspondence and test results are completed in a timely way.

• Ensure the practice follows the policy in place to provide and undertake clinical supervision of all staff that provide care to patients at the practice and share any learning with the staff member.

In addition the provider should:

• Further engage locum staff in practice meetings including those for palliative and end of life care.

• Proactively promote the national bowel cancer screening programmes to encourage uptake.

• Monitor the newly implemented system to ensure that practice stationary is stored securely and use of prescription stationery is tracked throughout the practice.

• Monitor the recently introduced systems to ensure that the practice adopted Patient Group Directions (PGDS) are current and available to staff.

This service was placed in special measures in June 2016. Insufficient improvements have been made such that there remains a rating of inadequate for providing well lead services and remains in special measures. The service will be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within a further six months.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice