The Care Quality Commission
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Archived: Whitestone Surgery

Overall: Inadequate read more about inspection ratings

82 Bulkington Lane, Whitestone, Nuneaton, Warwickshire, CV11 4SB (024) 7664 1911

Provided and run by:
Dr Sacha Simon

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of assessment: 13 December 2024. Whitestone Surgery is an NHS GP practice located within the Coventry and Warwickshire Integrated Care System (ICS) in an area of low deprivation. The practice delivers General Medical Services (GMS) to a patient population of approximately 2,400. Following the inspection in January 2024 the practice was rated inadequate overall and for all key questions but rated as requires improvement for caring. We took urgent action to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 we imposed a temporary suspension of six months on the registration of the provider in respect of the following activities: Diagnostic and screening procedures, Family planning, Maternity and midwifery services, Treatment of disease, disorder or injury and Surgical procedures. The caretaking team organised by NHS Warwickshire and Coventry Integrated Care Board (ICB) had continued to manage the practice for the extended 6 month suspension period to ensure people received continuity of care.

We carried out a focused assessment on 11 July 2024 to establish if the provider, Dr Sacha Simon could resume the delivery of regulated activities or the suspension must be extended further. The provider was unable to demonstrate that effective governance arrangements would be implemented to manage risks, performance and deliver safe care to patients who used the service, therefore the provider was suspended for a further 6 months.

We conducted this announced remote assessment of Whitestone Surgery to review the extended 6 months suspension and establish if the provider, Dr Sacha Simon could resume the delivery of regulated activities or we must extend the suspension further. The suspension was due to expire on 18 January 2025. As the provider was suspended from delivering regulated activities at Whitestone Surgery, the assessment focused on the planned changes to governance systems, processes and leadership to mitigate risk and ensure improvements were implemented and sustained. We assessed quality statements across the key question, well led but did not provide a rating as this was a focused follow up assessment.

We carried out an interview with the provider using video conferencing and reviewed their action plan and documents submitted as evidence. The provider was unable to demonstrate that effective governance arrangements would be implemented to manage risks, performance and deliver safe care to patients who used the service. The suspension was extended for a further 3 months.

The experience of people using the service was not assessed as part of this assessment.

During an assessment under our new approach

Date of assessment: 11 July 2024. Whitestone Surgery is an NHS GP practice located within the Coventry and Warwickshire Integrated Care System (ICS) The practice delivers General Medical Services (GMS) to a patient population of approximately 2,400. Following a short notice announced inspection on the 18 January 2024, the practice was rated inadequate overall and for all key but rated as requires improvement for caring. Due to the significant concerns we identified we took urgent action to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 we imposed a temporary suspension of six months on the registration of the provider in respect of the following activities: Diagnostic and screening procedures, Family planning, Maternity and midwifery services, Treatment of disease, disorder or injury and Surgical procedures. The suspension was due to expire on 18 July 2024. NHS Warwickshire and Coventry Integrated Care Board (ICB) who commissioned the services of the practice organised for a caretaking team to manage the practice for the 6 month suspension period to ensure people received continuity of care.

We conducted this announced remote assessment of Whitestone Surgery to review the six month suspension and establish if the provider, Dr Sacha Simon could resume the delivery of regulated activities or we extend the suspension further. We assessed 11 quality statements across the key questions safe, effective and well led but did not rate the assessment as this was a focused follow up. We carried out an interview with the provider using video conferencing and reviewed their action plan and documents submitted as evidence. The provider was unable to demonstrate that effective governance arrangements would be implemented to manage risks, performance and deliver safe care to patients who used the service, therefore the provider was suspended for a further 6 months.
 


 

12 January 2024

During a routine inspection

We carried out an unannounced comprehensive inspection at Whitestone Surgery on 12 January 2024. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 27 November 2018, 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 Whitestone Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

The inspection was carried out in response to concerns reported to us and information obtained through our monitoring call.

How we carried out the inspection

This included:

  • Conducting staff interviews in person.
  • Completing clinical searches and reviewing patient records on the practice’s computer system on the practice’s patient records system and discussing findings with the provider (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 site visit.
  • Speaking with members of the practice’s patient participation group.
  • Speaking with stakeholders.

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 have effective systems and processes to keep patients safe and protected them from avoidable harm.
  • Systems for safeguarding the practice’s most vulnerable patients were not fit for purpose.
  • Our clinical searches identified issues with safe management of medicines and prescribing.
  • The practice had not taken appropriate action in response to medicine safety alerts reviewed to ensure patients were kept safe.
  • We found deficiencies in the management of patient workflow in which there was a backlog of unprocessed and unmatched patient information.
  • There was insufficient clinical equipment available with which to assess or treat patients routinely or in an emergency.
  • The practice held limited emergency medicines on site and had not undertaken any risk assessments to ensure patients were not put at risk if recommended medicines were needed in an emergency.
  • The practice did not have effective systems for managing infection prevention and control.
  • There were gaps in recruitment information available and training records to demonstrate staff had the qualifications, skills and competencies for roles they undertook.
  • Patients did not always receive effective care and treatment that met their needs.
  • Our clinical searches and reviews found the care and treatment for patients with long-term conditions was not always delivered in line with standards and evidence-based guidance.
  • The practice was not proactive in identifying patients at risk of developing long-term conditions in order to provide necessary treatment.
  • Uptake of childhood immunisations and cervical cancer screening uptake was not meeting national standards and action plans were not in place to support improvements.
  • Results from the latest GP National Patient Survey showed results that were below local and national averages for patient experience and access.
  • The practice was unable to demonstrate that there were effective systems in place for identifying and managing incidents and complaints and that they were effectively used to support learning and improvement.
  • The practice was not managed in a way that promoted the delivery of safe and high-quality person-centred care. The leadership team were unable to demonstrate they had implemented effective governance systems and process to manage risks and performance and deliver safe and effective care. There was little evidence of supervision and oversight of clinical staff and of quality improvement initiatives.
  • However, we found the practice had a proactive and successful patient participation group that hosted a range of health and wellbeing services to support people in the locality.

We found several breaches of regulations. The provider must:

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

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 and assurances are made, we will consider the next steps and take action in line with our enforcement procedures. Special measures will give people who use the service the reassurance that the care they get should improve.

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

27/11/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating November 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Whitestone Surgery on 16 October 2018 as part of our inspection programme.

At this inspection we found:

  • Urgent same day patient appointments were available when needed. All patients we spoke with and those who completed comment cards before our inspection said they were always able to obtain same day appointments and access care when needed.
  • Patients’ needs were assessed and care delivered in line with current guidelines. Staff had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Results from the national GP patient survey revealed a high level of patient satisfaction about the care given at the practice and access to services which was either in-line with or above local and national averages. For example, 87% of patients who responded said that the last time they had a general practice appointment, the healthcare professional was good or very good at treating them with care and concern and 96% had confidence and trust in the healthcare professional they saw or spoke to.
  • Patients said GPs gave them enough time and treated them with dignity and respect.
  • The practice was actively engaged with the local community. The Patient Participation Group was involved with a number of community projects. This included an allotment project, an information technology group and a locally run carer’s café.

However there were areas of practice where the provider should make improvements:

  • The practice should continue to carefully review events as they occur to determine whether they meet the threshold to be a significant event.
  • The practice should ensure all meetings are consistently minuted.
  • Review the patients on the palliative care register to ensure they all have an appropriate care plan in place

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Whitestone Surgery on 3 November 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well led services.

Our key findings across all the areas we inspected were as follows:

  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. The practice ensured patients were seen the same day if needed.
  • Risks to patients were assessed and well managed. The practice had thoroughly reviewed all policies and procedures since it took over the practice two years ago.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned. Staff were encouraged to identify training and development that would benefit patients and the practice as a whole.
  • Data showed patient outcomes were high compared to the locality and nationally. Audits had been carried out which provided evidence the practice was driving improvement in performance to improve patient outcomes. The practice performance had considerably improved over the last two years.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. The Patient Participation Group had a strong leadership and was very active within the local community. The practice and key staff had a high positive profile within the local community.

We saw several areas of outstanding practice including:

  • A free ‘silver surfers’ group to encourage older patients to access practice services available on-line. This included on-line services used by the local pharmacy. Alongside this, patients were also taught basic computer skills relevant to their needs. This has helped to enable 45% of older patients registered with the practice to access practice services on-line.

  • A monthly ‘carer’s café’ for carers of patients. Light refreshments were available free of charge. This gave carers the opportunity to meet other carers and practice staff were available to give appropriate help and advice as well as emotional support.

  • A job club run in conjunction with the patient participation group (PPG). The practice recognised patient's well-being was also partially dependant on personal circumstances and sought to identify and meet patient's wider needs when possible.

There were areas where the provider should make improvements. The provider should:

  • Ensure the complaints procedure is correctly followed. Patients did not receive a written acknowledgement when their complaint was received by the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice