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The Surgery - Sloane Street Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 June 2019

This service is rated as Requires improvement

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out a comprehensive inspection at The Surgery – Sloane Street as part of our inspection programme.

The service provides a private GP service to adults and children.

The provider is registered with the Care Quality Commission for the regulated activity of Treatment of Disease, Disorder or Injury.

The lead GP partner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Forty-five people completed CQC comment cards prior to the inspection. All the feedback was very positive about the service. People said that they always received a quality service and they expressed high praise for all the staff.

Our key findings were:

  • The prescribing of high risk medicines was not carried out safely. A past serious incident involving a patient who was prescribed a high risk medicine without appropriate monitoring had not been learned from.
  • The provider had systems in place to keep clinicians up to date with current evidence based practice.
  • There was evidence of quality improvement activity including clinical audit.
  • Feedback from patients was very positive. Patients reported that staff were kind and caring and provided an excellent service.
  • Patients reported timely access to the service. They said that they could get an appointment time that suited them.
  • Complaints were taken seriously and used to improve the service.
  • The systems for monitoring safety were not always effective.

The areas where the provider must make improvements as they are in breach of regulations 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review safeguarding training requirements for non-clinical staff to ensure that it is in line with intercollegiate guidance.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Inadequate

Updated 21 June 2019

We rated safe as

Inadequate because:

  • The prescribing of high risk medicines was not carried out safely. A past serious incident involving a patient who was prescribed a high risk medicine without appropriate monitoring had not been learned from.

Safety systems and processes

The service

had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. However, reception staff had not completed safeguarding children training to level 2 which is a requirement stated in the Intercollegiate safeguarding guidelines. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control and a legionella risk assessment had been carried out.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff

had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

did not have reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • We reviewed high risk medicine prescribing at the inspection because CQC was aware of a past serious incident involving a patient who was prescribed a high risk medicine without appropriate monitoring. (Patients on high risk medicines must receive blood tests at regular intervals to reduce the risks of serious adverse effects on health and well-being). Our review found doctors did not prescribe high risk medicines in line with legal requirements and current national guidance. We reviewed a random sample of 15 individual patient records out of 23 in total for patients prescribed the high risk medicines, Methotrexate, Azathioprine, Lithium and Warfarin and found they were not consistently managed in a way that kept patients safe. Our review identified that one patient prescribed Methotrexate, one patient prescribed Azathioprine, three prescribed Lithium and two patients prescribed Warfarin had no record of recent blood tests prior to prescribing the medicines. Following the inspection we asked the provider for immediate assurances that they had taken action to review all patients on high risk medicines and mitigated any risks identified at the inspection. The provider sent us evidence that they had held a meeting to review all prescriptions issued for patients on high risk medicines, completed significant event analyses for those patients without appropriate monitoring and updated prescribing policies.

Track record on safety and incidents

The service

did not have a good safety record.

  • The practice was registered with CQC on 10 December 2010. There had been a serious incident in relation to a patient prescribed a high risk medicine without appropriate monitoring in January 2016. We inspected the practice in February 2018 and found no concerns in relation to high risk medicines. However, at this inspection we found evidence that patients prescribed high risk medicines were not being monitored appropriately.

Lessons learned and improvements made

The service did not always learn and make improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. There had been seven significant events documented in the last 12 months and we saw evidence that each incident had been investigated and discussed in staff meetings to share learning. For example, the surgery was affected by an IT phishing scam which affected some patients email addresses. Action was taken to inform all patients with an email address of the event and a General Data Protection Regulation (GDPR) expert was called in to check all documentation was safe. Training on GDPR was completed by staff and new policies introduced.
  • However, the systems for reviewing and investigating when things went wrong were not always effective. A serious incident from 2016 involving a patient prescribed a high risk medicine without appropriate monitoring had not been learned from as we found concerns in relation to high risk medicine prescribing at this inspection.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 21 June 2019

We rated effective as

Good

because:

  • The provider had systems in place to keep clinicians up to date with current evidence based practice.

  • There was evidence of quality improvement activity.

  • Staff had the skills, knowledge and experience to carry out their roles.

  • The service obtained consent to care and treatment in line with legislation and guidance

    .

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that in most cases clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service) except in relation to high risk medicines.

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines except in relation to high risk medicines.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements.The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For example, an audit was carried out to review the number of patients who had their allergy status accurately recorded on the patient record. The initial audit showed that 64% of patients had this information recorded on the patient record. Following the audit, the provider carried out a training session for the doctors, and a second audit showed an improvement to 70%. An antibiotic audit showed a 12% reduction in antibiotic prescribing for sore throat following the introduction of rapid strep testing.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical Council (GMC) and were up to date with revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, other private specialist services.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history except for patients prescribed high risk medicines. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example, local social services.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 21 June 2019

We rated caring as

Good

because:

  • Patients reported that they were always treated with kindness and their dignity and privacy was respected.

  • Feedback from 45 CQC comment cards was positive about staff and the service provided.

  • Patients reported that they were involved in decisions about their care and treatment.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. Patients were also told about multi-lingual staff who might be able to support them.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • The provider had identified 24 patients who had carer responsibilities and signposted them to support services. Free flu vaccinations were also offered.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 21 June 2019

We rated responsive as

Good

because:

  • Patients reported timely access to the service. They said that they could get an appointment time that suited them.

  • Vulnerable patients could access the service on an equal basis to others.

  • Complaints were taken seriously and used to improve the service.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, the provider had identified a demand for antenatal services.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, there was ramp access for patients with mobility issues.
  • Results from the providers in-house survey showed from 108 patients surveyed, a 99.6% satisfaction rate with the service provided.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, a patient complained there was a long wait for their call to be answered by staff. Following the complaint, measures were put in place to ensure enough staff were on duty to answer calls at busy times such as early mornings.

Well-led

Requires improvement

Updated 21 June 2019

We rated well-led as

Choose a rating because:

  • The system for monitoring the safe prescribing of high risk medicines was ineffective.

  • The system in place for learning from incidents and significant events was not always effective.

  • The practice was not registered with the CQC for all of the regulated activities it carried out.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to complaints. For example, we saw evidence from a complaint relating to payment processes where the provider had admitted to the patient that they got it wrong and apologised. However, not at all incidents had been learnt from.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. However, we found at the inspection the practice was not registered for all the regulated activities that it carried out. For example, it was not registered for diagnostic and screening procedures despite carrying out this regulated activity.

Managing risks, issues and performance

There were processes for managing risks, issues and performance. However, the processes for managing risk in relation to high risk medicine prescribing was ineffective.

  • The system for monitoring the safe prescribing of high risk medicines was ineffective. The provider had carried out monthly audits of patients prescribed high risk medicines, however the audits had failed to identify where prescriptions had been issued without evidence of recent blood tests carried out.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

  • The service used performance information which was reported and monitored and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, the provider carried out in-house patient satisfaction surveys. The provider had acted on staff feedback. For example, staff working hours had been changed to adjust workloads. The provider was also in the process of developing a patient participation group.
  • Staff could describe to us the systems in place to give feedback. For example, through staff surveys. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. Although there were shortfalls in some areas of governance.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

There were systems to support improvement and innovation work. For example, we saw evidence that the provider had facilitated a working group to improve dialogue between the NHS and private sector and they had taken steps to facilitate external learning from significant events and incidents.