Archived: Circuit Lane Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Circuit Lane Surgery on 24 January 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months and specific conditions were applied to the registration of the practice.

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. At that time we found some improvements and three of the six conditions applied were removed. However, the practice had not made sufficient improvements and remained in special measures. Both reports from the January 2017 and June 2017 inspections can be found by selecting the ‘all reports’ link for Circuit Lane Surgery on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced follow up comprehensive inspection on 12 October 2017. Overall the practice continues to be rated as inadequate.

Our key findings were as follows:

• There was a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
• We reviewed four 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 GPs and nursing staff had access to relevant and current evidence based guidance and standards. However, the care of patients diagnosed with asthma did not always follow these guidelines.
• 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 the QOF year April 2016 to March 2017 showed performance had fallen from the previous year. The practice was an outlier for meeting indicators of care for patients diagnosed with asthma and diabetes. Data supplied by the provider for the period April 2017 to October 2017 showed that overall the practice has made an improvement on the previous year.
• The practice had a clear and safe procedure for medicine reviews.
• Staff had the skills, knowledge and experience to deliver effective care and treatment. However, the clinical pharmacist and senior advanced nurse practitioner did not receive or access clinical supervision.
• 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 consistently below local and national averages.
• The practice had a system in place for handling complaints and concerns. There were notes of meetings where complaints were discussed and learning shared.
• 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 addressed in a timely way. For example, the risk associated with patients waiting for long periods of time on the phone to seek advice or book appointments.
• Practice specific policies were implemented and were available to all staff.
• 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.

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 care and treatment is provided in a safe way to patients

In addition the provider should:

• Operate a system of providing clinical supervision that is received and accessed by all relevant staff.

This service was placed in special measures in January 2017. Insufficient improvements have been made such that there remains a rating of inadequate for provision of effective, caring, responsive and well-led services. Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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 at Circuit Lane Surgery on 24 January 2017. The overall rating for the practice was inadequate. The practice was placed into special measure requires improvement 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 Circuit Lane Surgery on our website at www.cqc.org.uk.

This inspection was an unannounced focused inspection carried out on 2 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 24 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.
• 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.
• GP and nursing staffing levels had been increased to provide a wider range of appointments for patients. However, there remained reliance upon locum and agency staff and continuity of care could not be assured.
• 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 completed due to the practice prioritising improvement around the most significant risks.
• We found additional risks relating to monitoring of fridge temperature checks, monitoring and recording checks of emergency equipment and medicines, security of consulting rooms and disposable curtains were not changed on a regular basis. This demonstrated that whilst improvements had been made the provider had not appropriately monitored, mitigated and taken timely action against the risks and concerns we identified during the inspection.

However, there were also 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.

Following our previous inspection on 24 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 the improvements achieved thus far could not be tested for their sustainability and additional breaches of regulation were found. Special measures will continue to give people 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 24 January 2017 at Circuit Lane 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.

At this inspection we found:

• There was not appropriate learning from significant events and complaints to ensure improvements to safety and quality were made.
• 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 March 2016. Many of these records dated back to when the previous service provider was in place.
• 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.
• Patients on repeat medicines were not receiving timely reviews to ensure their medicines were being prescribed safely.
• Patient correspondence from external providers, such as hospital specialists, out of hours and paramedics was not consistently being dealt with in a timely way. We identified patients placed at risk of significant harm as a result of delays to their care and treatment.
• Referrals were not being processed in a timely way.
• The monitoring of the appointment system was poor and there was not adequate provision of appointments to meet the needs of the patient list.
• Patient feedback from comment cards stated they were treated with compassion, dignity and respect by clinicians and they were involved in decisions about their care and treatment.
• Risks to patients were not being recognised or action taken swiftly enough.
• Staff working at the practice were dedicated to the needs of the patient population and worked additional hours or through protected administration time to provide care to patients.
• There was not adequate action since 1 December 2016 to reduce the most significant risks to patients’ health, safety and welfare, which we reported to the provider at that time. The governance systems in place at the practice were inadequate to recognise and make the changes required to the practice.

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

The areas the provider must make improvements are:

• Ensure sufficient numbers of trained, skilled and experienced staff are available, and ensure ongoing training is maintained to protect patients from the associated risks related to their health and welfare caused by insufficient staffing.
• Ensure that patients can access the care and treatment they require in a timely way in order to reduce the risks posed to patients by not receiving adequate care or treatment.
• Implement a system to assess, mitigate and resolve risks associated with outstanding and future repeat prescription requests, referrals, medication reviews, patient correspondence, paper medical records, the low number of learning disability reviews, the storage, incomplete recruitment and staff checks and security of blank prescription forms and medicine safety alerts.
• Ensure leadership and governance systems are able to assess, monitor and improve the quality and safety of the services where improvements are identified as required and that the culture within the practice is conducive to making improvements. Specifically ensure that significant events and complaints are fully investigated and responded to, actions and learning undertaken where necessary and changes made to improve care and treatment including communication with staff and patients.

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 Circuit Lane Surgery on 1 December 2016. This was in response to concerns reported to CQC from patients that they were unable to book appointments and there were a series of concerns regarding access to care and treatment and patient safety. As a result of our findings on the 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 Circuit Lane Surgery are provided by One Medicare Ltd.

At this inspection we found:

• There were not sufficient 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 October 2015.
• 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 435 prescriptions waiting to be processed with the oldest being from 25 October 2016.
• Patient correspondence from external providers, such as hospital and paramedics, was not consistently being dealt with in a timely way. The system for acting on this correspondence posed a risk to patients’ health and welfare. For example, letters from external clinicians which required actions from GPs were not always acted on in a timely way.
• A search on the patient medical record system showed 21% of patients on less than four medicines had up to date reviews and for those on four or more 51% were up to date. This indicated that patients were frequently accessing medicines without receiving reviews to ensure their repeat prescriptions were appropriate.
• 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 make 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