Drs Leung, Gregson, Mallick, Sherrell & Mrs Hazeldine

We carried out an announced focused inspection at Drs Leung, Gregson, Mallick, Sherrell & Mrs Hazeldine better known as Forest & Badgerswood Surgery between 10 – 12 July. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Responsive – Requires Improvement

Well-led – Inadequate

Following our previous inspection on 10 August 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Drs Leung, Gregson, Mallick, Sherrell & Mrs Hazeldine on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out a focused inspection undertaking a site visit and remote clinical searches to review:

• Safe, Effective, Responsive and Well-led key questions
• Concerns identified during routine monitoring activity.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Obtaining feedback from external stakeholders.
• A short site visit.
• Staff feedback surveys.

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 found that:

• The practice provided care that did not keep patients safe and placed patients at high risk of avoidable harm. In particular, high-risk medicines were not always monitored and safety alerts were not appropriately actioned.
• Patients received ineffective care and treatment that did not meet their needs. In particular, staff did not always follow evidence-based guidance when providing treatment and care for patients. Patients with long-term conditions were not always monitored in line with national guidance.
• Patients could access care and treatment in a timely way.
• Governance processes were not always in place to ensure oversight of risk management was embedded. In particular, there were a lack of arrangements to ensure non-medical prescribers had a mechanism to raise treatment findings, concerns and clinical areas outside of scope of practice, which increased the risk of incidents occurring due to the lack of support. Oversight of mandatory training was not effective to ensure all staff completed the required training. Actions had not been taken to mitigate concerns identified within fire risk assessments.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Oversight of systems and processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should also:

• Improve the uptake of cervical cancer screening to eligible patients.
• Ensure Summary Plan for Emergency Care and Treatment (RESPECT) forms used for end of life patients are stored appropriately within the patient medical records in line with national guidance.

I am placing this service in special measures. Services placed in special measures will be inspected again in due course. If insufficient improvements have been made when we next inspect, such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This could lead to cancelling the provider’s registration or to varying the terms of their registration 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, and if there is not enough improvement, we could 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care