Archived: Queens Bower Surgery

We carried out an announced comprehensive inspection at Queens Bower Surgery on 10 December 2019 as part of our inspection programme. This inspection was carried out as Queens Bower Surgery had been rated inadequate and placed into special measures following their last comprehensive inspection in April 2019.

The key questions are now rated as:

Are services safe? – Requires improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out a comprehensive inspection at Queens Bower Surgery in January 2018 (the inspection report was published in May 2018). The practice was rated as requires improvement overall, with the safe and well-led domains rated as requires improvement. As a result, the

practice was issued with requirement notices for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

We carried out a further comprehensive inspection of Queens Bower Surgery on 2 April 2019 (the inspection report was published in July 2019). The practice was rated inadequate overall with ratings of inadequate for safe and well-led services, requires improvement for effective and caring services and good for responsive services. We issued the provider with two warning notices, one for Regulation 12 (Safe care and treatment) and the other for Regulation 17 (Good governance).

We carried out a focussed inspection of Queens Bower Surgery on 23 July 2019 and found that the practice had met the legal requirements as detailed in the warning notices issued on 30 April 2019.

At the most recent inspection in December 2019, we found that the provider had made improvements and satisfactorily addressed most areas of concern found at the previous comprehensive inspection. However, further action was required to ensure that the provider continued to improve their performance.

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.

The practice remains rated as inadequate overall, though the practice was rated as requires improvement for safe services and as good for caring and responsive services.

The practice was rated as inadequate for the population groups of people with long-term conditions, working age people (including those recently retired and students) and people experiencing poor mental health (including people with dementia). The practice was rated as requires improvement for the population groups of older people, families, children and young people and people whose circumstances may make them vulnerable.

We rated the practice as inadequate for providing effective services because:

• The practice had some policies and procedures, but clinical protocols required further development to support non-medical staff when carrying out some clinical tasks.
• The practice’s performance in a number of clinical areas was below local and national averages, including mental healthcare and childhood immunisation uptake rates.
• Only two of 21 patients with a learning disability had received an annual health check.
• A documented induction process was not in place for employed staff.
• Documented clinical supervision arrangements were not in place for temporary staff.

We rated the practice as inadequate for providing well-led services because:

• Leaders could not fully demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The practice had a clear vision, but it was not supported by a strategy and fully effective processes to provide high quality sustainable care.
• There were defined responsibilities, roles and systems of accountability to support good governance and management, however, we found these not to be fully effective.
• The practice did not have fully clear and effective processes for managing risks, issues and performance.
• The practice did not fully involve the public, staff and external partners to sustain high quality and sustainable care.
• There were some evidence of systems and processes for learning, continuous improvement and innovation, however, they could be further improved.

We rated the practice as requires improvement for providing safe services because:

• Safeguarding processes required strengthening to ensure arrangements were in place to follow up all non-attendance at children’s appointments, and to demonstrate that all adults at risk of significant harm were discussed at meetings with other health and social care professionals.
• Staff files did not always include all the relevant information to support safe recruitment.
• Staff immunisation records were incomplete.
• Fire alarm and emergency lighting systems documentation was not available to evidence records of servicing and maintenance by an external company.
• Appropriate storage was not in place for the effective management of clinical specimens.
• Staffing levels were not always sufficient and documented induction records for temporary staff were not in place.
• Up-to-date risk management plans and risk assessments, and evidence of annual reviews, were not in place for all patients with mental health conditions.
• Robust fail-safe processes for ensuring that two-week referral appointments and cervical screening results were received were not in place at the time of our inspection visit.
• Appropriate action had not been taken in relation to a significant event.

While the practice had only identified less than one per cent of their practice population as carers, we rated the practice as good for providing caring services because:

• Staff treated patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing responsive services because:

• The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way.

The area where the provider must make improvements is:

• 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 the provision of patient information to ensure that it is easily understandable.
• Continue to identify carers amongst the practice population.

This service was placed in special measures in July 2019. Insufficient improvements have been made such that there remains a rating of inadequate for the key questions of effective and well-led and this service will remain 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 BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out a comprehensive inspection at Queens Bower Surgery on in January 2018 (the inspection report was published in May 2018). The practice was rated as requires improvement overall, with the safe and well-led domains rated as requires improvement. As a result, the practice was issued with requirement notices for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

We carried out a further comprehensive inspection of Queens Bower Surgery on 2 April 2019. The practice was rated inadequate overall with ratings of inadequate for safe and well-led services, requires improvement for effective and caring services and good for responsive services. We issued the provider with two warning notices, one for Regulation 12 (Safe care and treatment) and the other for Regulation 17 (Good governance).

This inspection was an announced focussed inspection. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting the legal requirements as detailed in the warning notices issued on 30 April 2019.

You can read our findings from previous inspections by selecting the ‘all report’ link for Queens Bower Surgery on our website.

At this inspection we found:

• The practice had all the necessary emergency medicines in place to ensure they were able to respond to any event and adrenaline was now available in the clinical rooms where vaccines were given to patients.
• The doctors bag contained the necessary medical equipment and emergency drugs to allow the GP to manage acute situations whilst on home visits.
• A new safeguarding policy had been introduced and we saw that regular meetings took place between the practice and other relevant health professionals and minutes of these meetings were recorded.
• The practice had taken steps to reduce the risks of burns and scalds due to hot water temperatures. Work had begun to install thermostatic valves on taps to ensure the temperature remained safe and clear signage was in place to inform that the water might be hot.
• The practice had implemented a new training matrix to ensure oversight of staff training and staff had undertaken infection control training.
• The practice had introduced a new toolkit which would allow GPs to assess the level of various types of pain in people. For example, there was a pain assessment specifically tailored toward patients who were living with dementia.
• The practice had introduced new significant event policies, and these had started to be implemented which would allow the practice to learn from events to reduce any similar future occurrences.
• Systems were in place to ensure that equipment within the practice had been appropriately tested.

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

Dr Rosie Bennyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Queens Bower Surgery on 2 April 2019. At this inspection we followed up on the two breaches of regulations identified at a previous inspection on 11 January 2018.

Queens Bower Surgery received a previous CQC inspection in January 2018 (the inspection report was published in May 2018). The practice was rated as requires improvement overall with the safe and well-led domains identified as requires improvement. All population groups were rated as requires improvement. The practice was rated as requires improvement overall at the last inspection because:

• Improvement was required in relation to the management of clinical waste.
• Improvement was required in relation to managing emergencies and fire safety
• Governance arrangements required improvement to ensure staff received support and risk to people using the service were minimised.

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.

At this inspection, we have rated this practice as inadequate overall and we have rated the population groups as requires improvement overall.

We rated this practice as inadequate for providing safe services because:

• While the practice had made some improvements since our inspection on 11 January 2018, it had not appropriately addressed the Requirement Notice in relation to the monitoring and recording of emergency equipment and emergency medicines. At this inspection we also identified additional concerns that put patients at risk.
• Although the practice kept a register of patients with safeguarding concerns, there was no clear process to demonstrate what action the practice had taken. The safeguarding policy had not been reviewed or updated.
• Necessary safety checks had not been undertaken, some equipment in the practice had not received portable appliance testing (PAT).
• Infection prevention and control checks had not been undertaken to ensure risks to staff and patients had been minimised.
• Lessons from past events had not ensured improvement within the practice to minimise the occurrence of similar events.
• Some emergency medicines were not available, and there were no risk assessments in place to demonstrate why they were not available.
• Patient Specific Direction (PSDs) were not authorised to enable non-prescribing staff to administer vaccines.

We found a continued breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We rated the practice as inadequate for providing well-led services because:

• While the practice had made some improvements since our inspection on 11 January 2018, it had not appropriately addressed the requirement notice in relation to ensuring that governance arrangement were operated effectively to assess, monitor and mitigate risks to the service. At this inspection we also identified additional concerns that put patients at risk.
• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• The practice did not have clear vision, or credible strategy.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

We found a continued breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We rated this practice as requires improvement for providing effective and caring services because:

• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Staff did not receive regular supervision or appraisal and some training was overdue.
• Some performance data such as childhood immunisations and the Quality and Outcomes Framework was below local and national averages.
• These issues affected all population groups, therefore they were rated as requires improvement.
• There were more mixed comments than positive.
• The carers register was not accurate.

We rated the practice as good for providing responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• The practice should ensure their complaints process includes the handling of verbal complaints.
• The practice should ensure that there are systems in place to formally identify carers and that the register is accurate and is maintained.
• The practice should take steps to seek the views of patients and act on feedback to make improvements to the service.

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.

The service will be kept under review and if there is not enough improvement our enforcement action could be escalated.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care