Archived: Brookdale Surgery

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. The practice had been previously inspected on 11 April 2017, at which time all domains were rated as inadequate.

The key questions are rated as:

• Are services safe? –Inadequate
• Are services effective? – Inadequate
• Are services caring? – Inadequate
• Are services responsive? – Inadequate
• Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

• Older People – Inadequate
• People with long-term conditions – Inadequate
• Families, children and young people – Inadequate
• Working age people (including those retired and students – Inadequate
• People whose circumstances may make them vulnerable – Inadequate
• People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Brookdale Surgery on 2 November 2017. The practice had been previously placed in special measures on 2 April 2017, we were provided with an action plan detailing how they were going to make the required improvements. In addition, they wrote to us with updates on progress and actions that had been addressed. The inspection was to check the improvements made to date.

At this inspection we found:

Some areas within the practice had improved since the previous inspection in April 2017; all staff had now received appropriate training and had access to online training modules. The GP availability and involvement within the practice had increased by half a day per week. There had been improvements around infection control, fire safety and control of substances hazardous to health (COSHH). A new vulnerable patient register had been implemented. The practice had very recently invested in an external company to develop all practice policies. However we identified continuing breaches of regulation. Care planning were not taking place. The process for issuing medicines was not safe. There were insufficient day to day management structures in place that were needed to support on-going changes and to keep patients safe. There was a lack of nursing capacity giving rise to further risks to patients.

For example:

• The practice did not routinely review the effectiveness and appropriateness of the care it provided. Care and treatment was not always delivered according to evidence- based guidelines. Personalised treatment and care plans were not in place to meet patient’s individual needs or reflect their individual preferences.
• Repeat prescriptions, medicine reviews and re prescription authorisation processes were not always actioned appropriately by the clinical staff.
• The practice had invested in an external company who had developed a large number of new policies and processes to govern activity within practice. The management team were not able to embed or support staff in implementing the new governance system, due to lack of senior management and time.
• Patient safety alerts were not disseminated to clinical staff and there was no record that they had been actioned appropriately.
• There were insufficient day to day management structures or time in place to implement, embed and support the practices new internal governance changes required. Therefore leaving both patients and staff at risk.
• There was insufficient nurse cover to manage long term conditions of patients safely and effectively. For example, long term conditions reviews and assessments of the care needs for patients were not being carried out systematically or collaboratively.
• Control of substances hazard to health (COSHH) procedures and cleaning schedules had been newly implemented.
• A new infection control process and policy had been established with a full practice audit completed and some of the recommendations had been actioned. Risk assessments were in place for the controlling and preventing the spread of infection in areas of clinical practice.
• Staff had all completed online training related to their roles and had access to online training modules. The GP had the correct level of safeguarding training in place.
• The practice had a newly formed patient participation group (PPG), which had met once.
• The practice had identified 2% of the practice population as carers.
• Reception staff treated patients with compassion, kindness, dignity and respect

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.
• Ensure patients are protected from abuse and improper treatment.
• Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
• Ensure there is an effective system for identifying , receiving ,recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• 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:

• Review and monitor the locum nurse’s high DNA rates of clinical appointments.
• Continue to identify and support patients who are also carers
• Review the infection control folders for locum staff to follow the practice’s most up to date policy.
• Review the telephone system for patients accessing appointments.
• Consider replacing the worn chairs in the reception area.

This service was placed in special measures in June 2017. Insufficient improvements have been made such that there remains a rating of inadequate for Brookdale Surgery. 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 Brookdale Surgery on 11 April 2017. Overall the practice is rated as inadequate.

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there were no vulnerable patient registers and the safeguarding lead did not have knowledge of the in-house safeguarding processes. There were no care plans in place.
• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning or communication of the outcomes with staff.
• The practice had no clear leadership structure and there was insufficient leadership capacity and no accountability or responsibility from the lead GP. This was reflected by minimal systems and processes being in place to ensure safety and high quality care. There were limited formal governance arrangements.
• The arrangements for managing medicines in the practice, including emergency medicines and vaccines, were inadequate and solely managed by administrative staff. For example, the practice did not have the basic lifesaving medicines or equipment to treat patients in an emergency.
• The practice had no clear clinical processes for the monitoring of high risk medicines.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others, either locally or nationally.
• The practice did not have a comprehensive business continuity plan in place and staff were unsure what to do in an emergency.

The areas where the Provider must make improvements are:

• Ensure the risks to people's health and safety during any care or treatment are adequately assessed
• Ensure that all clinicians undertake care planning for all at risk patients.
• Ensure processes are implemented for reporting, recording, acting on and monitoring significant events, incidents and near misses.
• Ensure medicines are supplied in sufficient quantities, managed safely and administered to make sure people are safe, including those patients on high risk medicines, emergency medicines and equipment and repeat prescribing.
• Ensure processes are in place to maintain a safe practice environment with regards to the health and safety of patients, for example risk assessments, control of substances hazardous to health (COSHH), cleaning maintenance and infection control.
• Ensure that patients are appropriately safeguarded from abuse by having in place a satisfactory process for reporting, adding alerts, recording and acting on all vulnerable patients in the practice, and ensuring safeguarding training for all staff is in place.
• Ensure there is an accessible system for identifying, receiving, handling and responding to complaints.
• Ensure that an effective governance process is in place that includes adequate quality assurance and auditing systems or processes to keep patients safe.
• Ensure the practice seeks and acts on feedback from people using the service, those acting on their behalf, staff and other stakeholders, to continually evaluate the service and drive improvement.
• Ensure staff received appropriate support, training, professional development and supervision to carry out the role for which they are employed.
• Ensure that accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity are maintained.

In addition the provider should:

• Have a system in place to improve their identification of carers and offer more formal support to carers.
• Implement a Patient Participation Group (PPG) in order to identify and act on patients’ views about the service.
• Review the telephone system for patients accessing appointments.
• Make the practice leaflet available in paper format.
• Have regular documented clinical and non-clinical meetings.

We identified serious concerns, and drew these to the provider’s attention both during the inspection and immediately afterwards in writing.

Following the inspection and at the commission’s request evidence was submitted by the provider to ensure the most serious of issues linked to patient safety were being actioned or reviewed immediately to ensure patient safety was being mitigated. We received evidence that some action had been taken. However we were not completely satisfied that the Provider had immediately actioned all the issues identified.

I am placing this service in special measures. Due to the concerns identified the commission has begun the process in line with our enforcement procedures to prevent the provider from operating the service. Services placed in special measures will be inspected again within six months if they are still operating.

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