Archived: Elizabeth Street Surgery

We carried out an announced inspection at Elizabeth Street Surgery on 7 and 8 April 2021. Overall, the practice is rated as inadequate.

The key question ratings are as follows:

Safe - inadequate

Effective - inadequate

Caring – requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection under the previous provider’s registration on 14 March 2019 (published 1 May 2019), the practice was rated Good overall but was rated Requires Improvement in the effective key question and in the “families, children and young people” and “working age people” population groups.

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

Why we carried out this inspection;

This inspection was a comprehensive inspection to follow up on:

• Information of concern that we had received from whistleblowing and stakeholders.

How we carried out the inspection;

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included;

• Conducting staff interviews using video conferencing or telephone calls
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• Further remote communications for clarification.

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 have rated this practice as Inadequate overall, in the safe, effective, responsive and well-led key questions and for all population groups. The caring key question was rated requires improvement.

We found:

• Systems to identify and mitigate risks clinically or within the practice environment were ineffective. Safety concerns were identified during the inspection that had not been mitigated by the provider. For example, we saw that the nursing team had been vaccinating patients without the authorisation of a Patient Group Direction (PGD).
• The practice was unable to demonstrate that they had taken any action to improve areas of performance and quality that were lower than local and national averages. Systems of communication and call/recall within the practice were not effective or operating as intended and the practice was unable to demonstrate that allied health professionals including nurses were provided with structured supervision to ensure that they were working within their competencies.
• Practice coding errors and inconsistent management of registers of patients undermined confidence that these were accurate or that data provided was a true picture of practice performance.
• Patient feedback and satisfaction levels were low; the practice was unable to demonstrate that it had considered or taken any action to address areas of low satisfaction in relation to patient experience, in particular in relation to the availability of appointments.
• The systems in place to investigate and take action to address patient complaints were ineffective and not working as intended.
• The practice was unable to demonstrate that there was sufficient leadership or oversight for services delivered. There were systems of quality assurance in place that were ineffective. A high turnover of staff had meant any efforts to establish and embed systems and processes for effective service delivery had been unsuccessful.
• The culture in the practice was inconsistent with delivering high quality healthcare.

We found breaches to three of the regulations. The provider must:

• Ensure that care and treatment is provided in a safe way to patients
• Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should also:

• Make all policies and procedures accessible to staff.
• Establish a patient participation group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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