Archived: Crook Log Surgery

We carried out an unannounced inspection, following concerns raised with CQC, at Crook Log Surgery on 27 March 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as inadequate overall: inadequate for Safe and Well led, Requires improvement for Effective and Responsive, and Good for Caring.

Because of the concerns found at that inspection, we served the provider with warning notices for breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which we asked them to have become complaint with by 30 June 2019. The practice was placed into special measures.

We carried out a focussed follow up inspection on 3 July 2019. We carried out that inspection to check whether the provider had made enough improvements to become compliant with regulations 12 and 17. The practice was not rated on that occasion. We found that the provider had implemented improvements to address breaches of regulations 12 and 17, and all but one issue was now resolved.

This inspection, undertaken on 26 November 2019, was a comprehensive special measures follow up inspection. We have rated this practice as requires improvement overall.

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 and the public.

We rated the practice as inadequate for providing safe services because:

• Medicines management arrangements did not ensure that patients prescribed high risk medicines were not at risk of unsafe care and treatment.
• The practice maintained records of staff training on topics that supported their provision of safety systems and processes. However, we found there were a few gaps in the records of safeguarding training for clinical staff.
• The practice had systems in place to check that clinical staff had the appropriate immunisations. However, we found that the records did not demonstrate that all relevant staff had appropriate immunisations. These gaps were not well highlighted at previous CQC inspections.

We rated the practice as requires improvement for providing effective services because:

• Care and treatment was not consistently delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• Whilst child immunisation uptake rates had improved slightly since our last comprehensive inspection, they remained below the national target to achieve herd immunity.
• We found there was a lack of recent completed quality improvement activities on clinical activity.
• We found concerns with the management of high risk medicines that affected patients in some population groups.

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

• Data from the national GP patient survey showed patients rated the practice in line with local area and national averages for responses relating to their care and treatment experiences.
• Staff treated patients with kindness, respect and compassion.

We rated the practice as requires improvement for providing a responsive service because:

• Data from the national GP patient survey showed patients rated the practice lower than others for responses relating to timely access to the service. We saw evidence that the practice had taken action in response to these results, but there was a lack of evidence of impact of their actions.
• Extended hours appointments were available on Monday evenings.
• Complaints were managed in line with the practice’s complaints policy and were used to improve the quality of care.

We rated the practice as requires improvement for providing well-led services because:

• There have been recent changes in the leadership and management of the practice. The new team have implemented systemic changes and improvements in the governance of the service.
• There were clear roles and responsibilities to achieve effective management arrangements. However, some systems to support good governance were ineffective.
• There were clear and effective processes for managing risks, issues and performance. However, the practice did not have a systematic programme of clinical audit.
• The practice did not always act on appropriate and accurate information.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

This service was placed in special measures on 7 June 2019. Insufficient improvements have been made such that there remains a rating of inadequate for safe. This service remains in special measures and 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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Crook Log Surgery on 27 March 2019.

At that inspection, we found that:

• Staff had not received relevant training and support for their roles, which impacted their abilities to carry out their duties properly
• Staff recruitment checks were incomplete.
• Clinical premises and equipment was not being properly maintained to ensure it was fit for use.
• The practice did not stock hydrocortisone for acute severe asthma or severe or recurring anaphylaxis.
• We carried out a record review of four patient files and found that one patient had not been coded as pre-diabetic and had not been referred to a diabetic prevention programme.
• The practice did not have a programme of quality improvement.
• Polices had not been updated (since 2017) within the required timeframe (annual) and referred to members of staff that were no longer employees.
• Complaints were not always appropriately managed

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 rated the practice inadequate overall and they were placed into special measures. Because of the concerns found at that inspection, we served the provider with warning notices for breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance) of the Health and

Social Care Act 2008 (Regulated Activities) Regulations 2014 which we asked them to have become complaint with by 30 June 2019.

We carried out this focussed follow up inspection on 3 July 2019. We carried out this inspection to check whether the provider had made enough improvements to become compliant with regulations 12 and 17. The practice was not rated on this occasion.

At this inspection, we found that:

• The provider had implemented improvements to address breaches of regulations 12 and 17.
• The provider is maintaining ongoing engagement with the CCG and NHSE regarding improvement plans for the practice.
• Non-clinical staff we spoke with were happy with the changes and management plans in place since our last inspection.
• On review of the 11 items in the regulation 12 warning notice, we found that 8 were fully addressed. Actions were in progress for the three areas not fully addressed: DBS checks, staff immunisations and stocks of medicines for treating medical emergencies. The provider sent us evidence that all medicines not stocked were available in the practice shortly after our inspection.
• On review of the 15 items in the regulation 17 warning notice, we found that all were fully addressed.
• Diabetes reviews and management have been appropriately carried out.
• The provider had carried out an audit on diabetes diagnosis and coding (on their records system) following our last inspection.

The areas where the provider should make improvements are:

• Continue to review the arrangements for the management of patients with diabetes in the practice to ensure they are correctly diagnosed and have access to appropriate care and treatment.

We carried out an announced comprehensive inspection at Crook Log Surgery on 10 June 2016 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was good overall and requires improvement for providing a responsive service.

This inspection was an unannounced inspection, following concerns raised with CQC, which we undertook on 27 March 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements.

The practice was rated as inadequate for the safe and well-led key questions. This led to an overall rating of inadequate. Breaches of legal requirements were found, and requirement notices were issued in relation to patient safety, staffing and governance.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Crook Log Surgery on our website at www.cqc.org.uk.

We have rated this practice as inadequate overall and requires improvement for all population groups due to significant issues affecting all these groups.

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 and the public.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear and effective processes for managing risks, issues and performance.
• Staff did not all have safeguarding, fire and infection control training.
• Necessary recruitment checks including references had not been undertaken for all staff.
• Not all staff had evidence of their immunisation status on file.
• Clinic curtains had not been cleaned since December 2017.
• The practice had provided their reception staff with guidance about when patients should be

prioritised for medical attention.

We rated the practice as inadequate for providing well-led services because:

• There was a lack of governance arrangements to ensure that quality assurance processes were in place which led to improvements in patient outcomes.
• The practice culture did not effectively support high-quality sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• Practice policies had not been updated within the required timeframe and contained out-of-date information.

We rated the practice as requires improvement for providing effective services because:

• The provider had not taken steps to ensure staff had the knowledge to carry out their roles.
• We were not shown evidence of any quality improvement activity taking place at the practice.
• Childhood immunisation uptake was below target.

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

• Data from the GP Patient survey showed that the practice was in-line with local and national averages in indicators relating to patients’ experience of the practice.
• The practice had identified 2% of the patients as being a carer.

We rated the practice as requires improvement for providing a responsive service because:

• Data from the national GP patient survey showed patients rated the practice lower than others for some aspects accessibility to the service and their overall experience.
• Complaints were not responded to in a timely manner and were not used to improve the quality of care.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that persons employed at the practice have received appropriate training.

The areas where the provider should make improvements are:

• Continue to take steps to increase the uptake of all standard childhood immunisations and cervical screening.
• Proactively contact those patients who they knew had been bereaved due to the death of one of their patients.
• Review arrangements in place to enable staff to respond to medical emergencies, in particular, their ability to identify patients with sepsis.
• Review the process in place for the safe handling of requests for repeat medicines to ensure persons who are responsible for this role are adequately trained.

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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care