Archived: Priory Avenue Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Priory Avenue Surgery on 26 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

On 2 June 2017 we carried out a focused inspection at Circuit Lane Surgery to determine whether the practice was meeting the conditions applied following the January inspection.

The outcome of this inspection was that three out of six conditions imposed were removed. The current conditions in place during this inspection were:

• The registered person must implement a sustainable system to ensure outstanding and future repeat prescription requests, medication reviews, clinical correspondence and paper medical records requiring summarisation are reviewed and actioned without delay, to ensure patients are protected from risk of harm, at Priory Avenue Surgery. The existing backlogs for repeat prescription requests, medication reviews, clinical correspondence must all be cleared by 1st March 2017.The summarisation of paper records must be completed by 15th March 2017.
• The registered provider must ensure adequate capability, resource and capacity of all staffing groups in order to deliver a safe service. This includes providing adequate clinical staffing and appointments at Priory Avenue Surgery at all times to protect the health and welfare of patients .
• Effective and sustainable clinical governance systems and process must be implemented by 15th March 2017 at Priory Avenue Surgery. This is to ensure that all patients are able to access timely, appropriate and safe care; the systems and processes implemented protect patient safety and enable compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Both reports from the January 2017 and June 2017 inspections can be found by selecting the ‘all reports’ link for Priory Avenue Surgery on our website at www.cqc.org.uk. The practice has been managed by One Medicare Limited since September 2016 and they are registered to provide the services and this practice.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 10 October 2017. Overall the practice is now rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Our key findings were as follows:

• There was a system in place for reporting and recording significant events. However, this did not include a means of identifying patients involved in the event.
• The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. However, we found staff had acted as chaperones without the appropriate knowledge of how to undertake this appropriately.
• The practice did not maintain appropriate standards of cleanliness and hygiene. We observed some areas of the treatment room and clinical rooms and the non-clinical areas on the ground floor of the premises to be dirty with a thick layer of dust. There was no cleaning schedule in place on the day of inspection.
• We reviewed five personnel files and found appropriate recruitment checks had been undertaken prior to employment.
• The practice had adequate arrangements in place to respond to emergencies and major incidents.
• The practice assessed needs and delivered care in line with relevant and current evidence based guidance and standards.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. (QOF is a system intended to improve the quality of general practice and reward good practice). The most recent data from 2016/17 showed positive performance within the current QOF year (ending in March 2017).
• The practice had a clear and safe procedure for medicine reviews.
• Staff had the skills, knowledge and experience to deliver effective care and treatment. The systems for supervision of clinical staff did not ensure that new team members always felt supported in their role.
• The information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way through the practice’s patient record system and their intranet system.
• Staff sought patients’ consent to care and treatment in line with legislation and guidance. Although further understanding of the Mental Capacity Act 2005 was needed.
• We observed members of staff were courteous and helpful to patients and treated them with dignity and respect.
• Results from the national GP patient survey were mixed. The practice was below average for its satisfaction scores on consultations with GPs and nurses.
• Friends and family test results showed that patient satisfaction had increased since January 2017 then decreased in September 2017.
• Patients told us they felt involved in decision making about the care and treatment they received.
• The practice had an effective system in place for handling complaints and concerns.
• The provider’s vision to deliver high quality care and promote good outcomes for patients but this was not always supported by effective leadership and governance processes.
• There were arrangements for identifying, recording and managing risks within the practice; however, some risks were not identified.
• Clinical meetings were not consistently carried out and documented.
• Practice specific policies were implemented and were available to all staff. Although not all policies were followed, such as the chaperone policy.
• The practice had used most of their resources since the inspection in January addressing the areas of high risk and the clinical and administrative backlog. This had resulted in little opportunity for innovation or service development. There was also minimal evidence of learning and reflective practice.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

This service was placed in special measures in January 2017. Insufficient improvements have been made such that there remains a rating of inadequate for well-led. Therefore the service will remain in special measures. The service will be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we may move to close the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Our previous announced comprehensive inspection at Priory Avenue Surgery on 26 January 2017 found breaches of regulations. The overall rating for the practice was inadequate. The practice was placed into special measure and conditions were applied to the registration. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Priory Avenue Surgery on our website at www.cqc.org.uk.

This inspection was an unannounced focused inspection carried out on 1 June 2017 to check that the practice was complying with the conditions imposed upon their registration arising from the breaches in regulations that we identified in our previous inspection on 26 January 2017. This report covers our findings in relation to those conditions and also additional improvements made since our last inspection. Due to the nature of this inspection the ratings have not been reviewed.

Our key findings were as follows:

• Clinical governance systems in place showed improvement but were in early stages of implementation and it was too early to evaluate the sustainability of the structures and systems put in place.
• GP and nursing staffing levels had been increased to provide a wider range of appointments for patients. The evidence indicates that although sufficient staff are rostered to provided clinical services the practice remains reliant upon high cost locum and agency staff to deliver advice and treatment.
• Governance structures had been put in place including daily team huddles and weekly clinical meetings.
• There was a system in place to ensure test results were reviewed and action taken, when required, in a timely manner.
• A system was in place to ensure the timely production of repeat prescriptions.
• A process had been introduced to ensure correspondence from hospitals and other agencies was filed into patient records and reviewed by clinicians in an appropriate timescale.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Training needs had been identified but not all mandatory or relevant training had been completed. The timetable for completion of identified training had not been kept up to date.
• Annual reviews for patients with long term conditions had demonstrated improvement. However, reviews of patients on less than four or four or more repeat medicines had been decreased compared to the previous inspection.
• We found additional risks relating to monitoring of fridge temperature checks and disposable curtains were not changed on a regular basis. This demonstrates that whilst improvements have been made the provider has not appropriately monitored, mitigated and taken timely action against the risks and concerns we have identified in this notice.

The areas where the provider must make improvements are:

• Maintain effective and sustainable systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure the monitoring of medicine fridge temperatures is completed in accordance with the practice policy and action taken when required.
• Review and improve the systems in place to ensure the risk of cross infection is minimised.
• Ensure all staff has received training relevant to their role.

In addition the provider should:

• Improve the outcomes for patients with dementia.

Following our previous inspection on 26 January 2017 we applied six conditions upon the practice registration that required urgent action by the practice. The improvements found at this focussed inspection have enabled CQC to remove three of these conditions. However, the practice remains in special measures as further improvement is required and additional breaches of regulation were found. The systems were in their early stages of implementation and their sustainability could not be assessed. Special measures will continue to give patients who use the service the reassurance that the care they get should improve.

The service will be kept under review and if needed could be escalated to further 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on Thursday 26 January 2017 at Priory Avenue Surgery. We undertook this inspection following urgent action taken as a result of our unannounced inspection on 1 December 2016 to identify whether improvements had been made and review all aspects of the service. We have rated the service as inadequate and taken further urgent enforcement action (subject to appeal) as a result of our findings.

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

• Risks to patients were not assessed or well managed.
• The practice had the necessary equipment and procedures for dealing with emergencies. However, regular checks of emergency medicines and equipment were not undertaken appropriately.
• Staffing levels were not appropriate to ensure the practice was staffed to a safe level and to ensure appropriate care was given to address patient’s health needs.
• Effective systems to assess, monitor and improve the quality and safety of the services provided had also not been implemented. We found examples of poor care resulting from a lack of appropriate systems to monitor and address the backlog of clinical and administrative tasks.
• There was a significant backlog of patient correspondence not yet reviewed or filed onto the record system. This included records of discharge summaries, Out of Hours, walk-in centre reports and A&E discharges. There was a backlog of patient referrals dating back to November 2016 and new patient summarising back to October 2016.
• Staff did not always have the skills, knowledge and experience to deliver effective care and treatment.
• Data from the friends and family test had shown a steady decline in patient satisfaction since September 2016.
• Patients said there was a lack of continuity of care due to the use of locums and there were sometimes problems accessing an appropriate appointment.
• Patients were referred to other services, such as accident and emergency or the local walk in centre, when the practice could not meet the patient’s needs due a lack of appropriate staffing.
• There was a lack of strategy and supporting business plans to reflect and implement the provider’s vision and values.
• The governance framework did not support the delivery of safe, effective and responsive care. We found significant risks were not assessed appropriately to determine the high level of impact to patient safety.
• There was no clear and embedded leadership structure at the practice.
• Staff told us there was not an open culture within the practice and although they had the opportunity to raise any issues they did not feel confident and supported in doing so.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• Since the inspection in January 2017, North and West Reading Clinical Commissioning Group have provided significant support to Priory Avenue Surgery to ensure the highest levels of risk and concern have been addressed urgently.

The areas where the provider must make improvements are:

• Ensure effective and sustainable clinical governance systems and process are implemented to assess, monitor and improve the quality and safety of the services provided. Including; the implementation of a sustainable system to ensure outstanding and future medication reviews are undertaken; Docman correspondence is reviewed; paper medical records requiring summarisation are actioned without delay; and significant events are shared with staff at all levels and is used make improvements within the practice.

• Assess the risks to the health and safety of service users of receiving the care or treatment in respect of the proper and safe management of medicines. This includes improving the monitoring of emergency medicines and equipment to ensure it is fit for purpose and suitable to be used in an emergency; and patient group directions are used appropriately.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to deliver a safe service.
• Ensure a system is implemented to effectively identify, receive, record, handle and respond to complaints made by service users.

The areas where the provider should make improvements are:

• Ensure patient and staff feedback is collated and used to influence and encourage positive change within the practice.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We undertook an unannounced responsive inspection of Priory Avenue Surgery on 1 December 2016. This was in response to concerns reported to CQC regarding a lack of appointments and clinical staff to provide safe care. As a result of our findings on inspection we have taken urgent action. We have issued conditions on the provider’s registration and told them they must make improvements to the levels of staffing, the safety and quality of services and their governance processes.

Services from Priory Avenue Surgery are provided by One Medicare Ltd.

At this inspection we found:

• There were insufficient numbers of skilled and experienced staff deployed to ensure patients received the care they needed
• There was a backlog of patient record summarisation (the incorporation of new patients’ medical records to the practice’s record system), which dated back to August 2016.
• Patients reported significant delays in obtaining repeat prescriptions. This left patients at risk as they were unable to access their medicines in a timely way. On the day of inspection, there were 27 prescriptions waiting to be processed. These were outside of the usual 72 hour turnaround period. The oldest being from 21 November 2016.
• Patient correspondence from external providers, such as hospital and paramedics, was not consistently being dealt with in a timely way. The delay in acting on this correspondence posed a risk to patients’ health and welfare.
• Governance systems did not ensure that quality improvements were made in a timely way. For example, when risks to patients were identified they were not always acted on or mitigating actions undertaken to address the seriousness and reduce the level of risk to patients.
• Staff working at the practice were dedicated to the needs of the patient population. We found they were working additional hours or through their protected administration time to provide care to patients.

The areas the provider must improvements are:

• Improve the level of qualified, skilled and trained staff deployed to protect patients from the associated risks related to their health and welfare and ensure that patients can access appointments in a timely way.
• Ensure governance systems to assess, monitor and improve the quality and safety of the services are reviewed. This includes the implementation of a system which effectively assesses and mitigates risk. The provider must urgently address the continued risks relating to overdue repeat prescription requests, referrals, medication reviews, patient correspondence and paper medical records.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice