Great Staughton Surgery

We carried out an announced comprehensive at Great Staughton Surgery on 11 January 2023. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Good

Well-led - Inadequate

We previously inspected the location under its previous provider on 13 February 2017, the practice was rated good overall and for all key questions. The practice changed provider and inherited the regulated history and ratings of the predecessor. The new provider registered with the Care Quality Commission (CQC) in June 2019.

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

Why we carried out this inspection

We carried out this comprehensive inspection to provide a rating of the location under the new provider and in line with our inspection priorities.

This was a comprehensive inspection and therefore we have reported on all key questions; safe, effective, caring, responsive and well-led .

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.
• A short site visit.
• Staff questionnaires.

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 did not provide care in a way that kept patients safe and protected from avoidable harm.
• Not all patients received effective care and treatment that met their needs. Patients with long-term conditions were not being reviewed effectively, coding was inaccurate and this put patients at risk.
• The practice did not have an effective quality improvement programme.
• The practice did not ensure that all medicines were prescribed safely to all patients. This included some high-risk medicines and controlled drugs.
• Medicine reviews were not always effective or completed in a timely manner.
• Oxygen for use in an emergency had expired and we found that there was a lack of an effective system to check expiry dates of equipment used at the practice.
• Patient safety alerts were not being managed effectively.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice respected patients’ privacy and dignity and patient confidentiality was maintained throughout the practice.
• The management and leadership of the practice did not promote the delivery of high-quality, person-centre care.
• The practice did not operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found two breaches of regulation. The provider must:

• 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.

In addition, there were areas the provider could improve and should:

• Continue to review and reduce where appropriate, prescribing rates for antibacterial medicines.
• Continue to identify, contact and assess patients who are eligible for NHS health checks.

As a result of the concerns identified we issued a Section 29 warning notice in relation to a breach of Regulation 12 Safe Care and Treatment.

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 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.

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 Hospitals and Interim Chief Inspector of Primary Medical Services