The Care Quality Commission
  • Doctor
  • GP practice

Archived: Cater Street Surgery

Overall: Inadequate read more about inspection ratings

1 Cater Street, Kempston, Bedford, Bedfordshire, MK42 8DR (01234) 849090

Provided and run by:
Dr Altaf Muhammad Ali

Important: The provider of this service changed - see old profile
Important: We are carrying out a review of quality at Cater Street Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

29 Jan 2020

During an inspection looking at part of the service

We carried out an announced focused inspection of Cater Street Surgery on 29 January 2020. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation set out in warning notices we issued to the provider for Regulation 12 Safe care and treatment and Regulation 17 Good governance.

The practice received an overall rating of inadequate at our inspection on 13 November 2019 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full comprehensive report from the November 2019 inspection can be found by selecting the ‘all reports’ link for Cater Street Surgery on our website at www.cqc.org.uk.

Our inspection team was led by a CQC inspector and included a GP specialist advisor.

Our judgement of the quality of care at this service is based 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.

This service was placed in special measures in November 2019. Following a further inspection in January 2020, where we found insufficient improvements we took action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. We will now move to close the service by adopting our proposal to cancel the providers registration. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Our Key findings:

  • The practice was not compliant with the warning notices issued in November 2019.
  • Some improvements to the oversight of safety alerts had been made however, records we checked showed appropriate actions were not being taken.
  • Some improvements to the systems to manage patients who were prescribed medicines that required additional monitoring had been introduced however, these were not effective and clinical records we checked showed that not all patients had received appropriate blood testing prior to prescribing.
  • The practice had developed a safeguarding register and had met with a health visitor to discuss vulnerable children however, there were no systems in place to discuss vulnerable adults with community teams.
  • Some of the backlog of new patient summaries had been cleared however, there was still records from December that had not been completed. The practice could give no assurance that there was not safeguarding information in these records.
  • The methods of managing safeguarding correspondence into the practice was lacking.
  • A fire risk assessment and legionella risk assessment had been completed and we saw some remedial work had taken place however mitigating actions to reduce the risk of legionella, such as water temperature checks, were not being completed.
  • The practice did not hold complete records of staff immunisations and vaccinations.
  • There was ineffective recall systems to ensure patients had received reviews and care plans were not consistently being completed.
  • Staff had completed training in safeguarding, fire and infection prevention and control however, two members of clinical staff had not completed basic life support training in the last twelve months and one member of staff had not completed equality and diversity training.
  • There had been no improvements to increase access to the practice via the telephone or availability of appointments.
  • Some assessment of clinical competency had been completed, however this was lacking and there were no plans in place to address problems with staff performance.
  • Communication with staff remained poor and some staff told us they felt unsupported. They were unaware of new processes that had been developed.
  • There was ineffective governance systems and a lack of a cohesive management team.

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.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

13 Nov 2019

During a routine inspection

We carried out an announced comprehensive inspection at Cater Street Surgery on 13 November 2019 following our annual regulatory review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

At the last inspection in April 2017 we rated the practice as good overall.

Our judgement of the quality of care at this service is based 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.

The practice is rated as inadequate overall.

The practice is rated as inadequate for providing safe services because:

  • Not all staff had received the appropriate level of safeguarding for their role.
  • Patient safety alerts were not appropriately acted upon and we saw evidence that patients were not receiving evidence-based treatments.
  • A fire risk assessment had not been completed. Mitigating actions that had been identified were not being conducted.
  • A legionella risk assessment had not been completed.
  • The system to manage medicines that required additional monitoring was ineffective and we saw evidence of patients not receiving the appropriate blood tests prior to prescribing.
  • Learning from significant events and incidents was poor and not shared with staff.

The practice is rated as inadequate for providing effective services because:

  • The practice did not share up-to-date guidance with staff, including locum GPs.
  • The system for follow up and recall of patients was ineffective.
  • Care plans and reviews had not been completed for those on disease registers or receiving repeat medicines.
  • The practice did not liaise with community teams to ensure coordinated care for complex or vulnerable patients.
  • There were gaps in staff training.
  • The appraisal system was lacking and there was no oversight of clinical practice for both permanent and locum staff. We saw evidence that nursing staff had been asked to work outside of their level of competence.

The practice is rated as requires improvement for providing caring services because:

  • The GP national survey results were lower than local and national averages.
  • The resources for carers needed updating.

The practice is rated as requires improvement for providing responsive services because:

  • The practice was unaware of the Accessible Information Standard and did not provide information in a format that would be appropriate for all patients with a disability.
  • Patients told us they found it difficult to make an appointment or access the practice via the telephone.
  • There was no evidence that learning was taken from complaints or that complaints were shared with staff. Patients were not given details of how to escalate concerns to the Parliamentary and Health Service Ombudsman.

The practice is rated as inadequate for providing well-led services because:

  • The practice had ineffective governance systems in place.
  • The practice had not assessed all risks to patient safety or put mitigating actions in place.
  • The Whistleblowing policy was ineffective, and staff were unaware of the local Freedom to Speak Up Guardian.
  • There was no evidence of innovation or improvement activity.
  • There was no succession planning in place.
  • There was poor communication with staff and they felt unsupported.

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.
  • Establish systems to receive and act on complaints.

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.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care



2 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cater St Surgery on 2 November 2016

Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff were aware of their responsibilities in helping to safeguard and protect patients.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice team worked well with multidisciplinary teams, including community and social services to plan and implement care for patients.
  • The practice held regular staff and clinical meetings where learning was shared from significant events and complaints.
  • Patients we spoke to and comments cards reflected that patients felt they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. However, National GP Patient Survey results were below average.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The majority of patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had enrolled in the Electronic Prescribing Service (EPS).
  • Dementia patients were well monitored and supported.
  • 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 provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice