Archived: West End Surgery

Letter from the Chief Inspector of General Practice

This service was previously registered and inspected under a previous provider. The new registration as a partnership took effect from 25 August 2017, which included one GP partner who had been the previous registered provider. Although this was a new registration as a partnership, the practice had been operating under these managerial arrangements since August 2016 with delays in finalising the new registration with the CQC.

The Care Quality Commission (CQC) initially carried out an announced comprehensive inspection at West End Surgery in March 2015 when the practice received an overall requires improvement rating. A further inspection on 11 January 2016 rated the practice as inadequate for providing safe, effective, responsive and well-led services and requires improvement for providing caring services. The overall rating for the practice was inadequate and it was placed in special measures for a period of six months. Following a subsequent inspection on 6 September 2016, West End Surgery was rated requires improvement overall and requires improvement within each of the five domains. A requirement notice was issued following this inspection to ensure action was taken to meet the legal requirements within our regulations in respect of pre-employment recruitment checks. However, the practice was found to have increased its capacity, both in terms of management and clinical staff, and it was identified that changes were being made to sustain improvements in quality. The practice was therefore taken out of special measures.

The full reports from all of the previous inspections relating to the former provider can be found by selecting the ‘all reports’ link for West End Surgery on our website at www.cqc.org.uk.

We carried out this unannounced comprehensive inspection at West End Surgery on 2 and 13 October 2017. This inspection was undertaken due to the change in the registered legal entity providing the service, which had changed from a single-handed GP to a partnership in August 2017. The inspection was unannounced due to information of concern reported to the CQC. Overall the practice is rated as inadequate.

Our key findings were as follows:

• The practice had insufficient operational management in place. The practice management did not have an ongoing or regular presence on site. In addition, there was limited evidence of clinical leadership to drive improvements within the practice.
• Two of the three GP partners did not work at the practice, and were part of the IMH Group, which is a network of primary care sites across the country whose aim is to help the NHS to deliver its five year plan. The group manages over 50 sites, including GP practices, walk-in centres, and urgent care centres.
• There were limited formal governance arrangements in place and the clinical oversight of processes needed to be strengthened.
• Patients were at risk of harm because some systems and processes were not in place to keep them safe. For example, the practice did not have effective procedures in place to deal with alerts received from the Medicines and Healthcare products Regulatory Agency (MHRA) or alerts related to patient safety. We found that some alerts had not been reviewed to keep patients safe.
• Staff told us that they assessed patients’ needs and delivered care in line with current evidence based guidance. However, we were not assured that there were effective systems to ensure guidance was acted upon, and notes from clinical meetings did not reference that new guidance had been discussed.
• Staff fulfilled their responsibilities to raise concerns, and to report incidents. The incidents were reviewed by clinical staff and managers, but we found that there was greater scope for learning and providing evidence of any agreed actions being completed. We saw examples that similar issues had recurred as effective learning had not been implemented by the practice.
• We saw examples of poor compliance with infection control standards. Despite several audits by the local Infection Prevention and Control Team over the course of the last 12 months, the practice was still failing to meet a range of assessment criteria and act upon recommendations.
• The practice was not operating effective systems to ensure they had assessed and put control measures in place to manage all identifiable risks. For example, they had not assessed risks associated with fire and other environmental and health and safety risks. This was exacerbated by the fact that areas of the premises were used to accumulate old and discarded equipment.
• Most patients said they were treated with compassion, dignity and respect and they were involved in decisions about their treatment. Data from the latest national GP patient survey showed that there had been improvement since the previous survey 12 months earlier.
• Information about services and how to complain was available on request and easy to understand. However, the internal procedure for handling complaints and the system for responding to complaints needed to be improved.
• Staff training records could not be provided at the time of our inspection. We found that there was insufficient evidence to confirm staff had the appropriate skills and knowledge to deliver care and treatment.
• Patients said they were generally able to access urgent appointments but there was mixed feedback from patients about their experience in obtaining a routine appointment, or seeing the same GP for continuity.
• A refurbishment plan had been considered to address areas of the premises which had been identified for improvement, including better access for patients with a disability, but this was still awaiting financial support.
• Medicines were not always stored safely and we found that some medicines had exceeded their expiry date. The management of blank prescriptions within the practice needed review to ensure that they were fully secured in line with the practice policy and national guidance.
• Regular team meetings for the whole practice team were not taking place. The last meeting had occurred in November 2016. We found that when issues had been raised by staff, they had not always been acted on.
• There was no completed documentation to evidence that new staff received an induction and support. Competency assessments were incomplete and did not cover all of the relevant responsibilities and tasks undertaken.
• Not all staff had received regular appraisals. Those inductions that had been completed were brief and did not provide clear objectives or feedback on the role.
• A range of policies and procedures were in place to govern activity within the practice. However, we saw evidence that these were not always adhered to in practice, and not all staff were aware how to access them.

Importantly, the provider must make improvements to the following areas of practice:

• Ensure care and treatment is provided in a safe way to patients, for example, by reviewing all relevant patient safety alerts, including those issued from the Medicines and Healthcare products Regulatory Agency (MHRA), and taking timely and appropriate follow up actions; and proper and safe management of medicines.
• Ensure that the premises are suitable for the purpose for which they are being used. This includes upholding standards of hygiene and ensuring the property is properly maintained and compliant with health and safety regulations.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This includes the effective management of complaints and systems to monitor internal processes.

The areas of practice where the provider should make improvements are:

• Improve the identification of carers in order to provide them with appropriate support.
• Improve the uptake of annual learning disability health checks.

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 urgent action has been taken by the imposition of conditions on the location’s registration with the CQC.

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