Archived: St Mary's Island Surgery

We carried out an announced comprehensive inspection at St Mary’s Island Surgery on 9 July 2019. The overall rating for the practice was Requires Improvement. The full comprehensive report on the July 2019 inspection can be found by selecting the ‘all reports’ link for St Mary’s Island Surgery on our website at www.cqc.org.uk.

After our inspection in July 2019 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced comprehensive follow-up inspection on 14, 15, 17, 20 and 21 January 2020 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 9 July 2019. This report covers findings in relation to those requirements.

This practice is now rated as Inadequate overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? – Inadequate

We rated the practice as Inadequate for providing safe services because:

• The practice needed to make further improvements to systems, practices and processes to help keep people safe and safeguarded from abuse.
• The practice needed to make further improvements to the way risks to patients, staff and visitors were being assessed, monitored or managed.
• Although the practice had made some improvements, staff still did not always have the information they needed to deliver safe care and treatment.
• The practice needed to make further improvements to the arrangements for medicines management to help keep patients safe.

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

• Care and treatment were still not always delivered in line with current legislation, standards and evidence-based guidance.
• The practice needed to make further improvements to their programme of quality improvement activity and how they routinely reviewed the effectiveness and appropriateness of the care provided.
• Child immunisation uptake rates were still lower than the target percentage of 90% or above in all four indicators.
• The practice’s performance in four out of five cancer indicators had deteriorated.
• All staff were still not up to date with all essential training.
• All staff were still not receiving regular appraisals.
• The practice did not always act on incoming correspondence from other organisations in a timely manner.

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

• National GP patient survey results had improved since our last inspection in July 2019 and feedback we received from patients was predominantly positive about their experience of being involved in decisions about care and treatment. However, we also received negative feedback from patients about the care they received regarding: some staff being rude; delays with referrals to other providers for tests; investigations and treatment not being carried out in a timely manner; and difficulties in obtaining repeat prescriptions.

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

• The practice organised services to meet patients’ needs. However, there were still not sufficient staff with which to deliver services to meet patients’ needs.
• Requests for home visits were still not always being triaged by a clinician in a timely manner.
• People were still not able to access care and treatment from the practice within an acceptable timescale for their needs.

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

• Local clinical leadership was now limited, remained complex and still did not always function as intended by the provider.
• The processes and systems to support good governance and management were not always effective.
• The practice needed to make further improvements to their processes for managing risks and issues.
• The practice needed to make further improvement to adequately manage and improve some performance that fell below local and national averages.
• Completed clinical audit cycles that drove improvement were limited.
• The practice did not always act upon incoming appropriate and accurate information.

The areas where the provider must make improvements 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.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• 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 their duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Stock the emergency antibiotic cefotaxime as soon as it becomes available again to order.
• Provide details of the Parliamentary and Health Service Ombudsman when replying to all complainants.
• Revise the system to help keep all governance documents up to date.

I am placing the service in special measures. Services placed in special measures will be inspected again in 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 reassurance that the care they get should improve.

Dr Rosie Benneyworth MB BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at St Mary’s Island Surgery on 9 July 2019 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice’s systems, processes and practices did not always help to keep people safe.
• Risks to patients, staff and visitors were not always assessed, monitored and managed in an effective manner.
• Staff did not always have the information they needed to deliver care and treatment to patients.
• The arrangements for managing medicines did not always help keep patients safe.
• The practice learned and made improvements when things went wrong.
• Published QOF data from 2017 / 2018 showed that the practice’s performance for all QOF related indicators (with the exception of asthma) was in line with local and national averages.
• Published results showed the childhood immunisation uptake rates for the vaccines given were below the 90% minimum target. However, unverified data showed that the uptake of child immunisations and boosters had improved to 95% and 83.6% respectively as at 1 April 2019.
• Published Public Health England results showed that the practice’s performance for cancer indicators was either in line with or higher than local and national averages. The exception was the uptake for cervical screening which was below the 80% target for the national screening programme.
• Staff had the skills, knowledge and experience to carry out their roles. However, not all staff were up to date with essential training.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient feedback about the practice was mixed and results from the national GP patient survey were in line with but mostly below local and national averages.
• The practice respected patients’ privacy and dignity.
• The practice organised services to meet patients’ needs. However, they did not always have sufficient staff at St Mary’s Island Surgery to deliver these services.
• Patients were not always able to access care and treatment from the practice within an acceptable timescale for their needs.
• Local clinical leadership was limited, and local leaders were not always aware of the performance of St Mary’s Island Surgery or the plans to improve performance where necessary.
• There were processes and systems to support good governance and management. However, not all staff were fully aware of their own roles and responsibilities in relation to governance.
• The practice involved the public, staff and external partners to sustain high-quality and sustainable care.
• There were systems and processes for learning and continuous improvement.

The areas where the provider must make improvements 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.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• 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 their duties.

The areas where the provider should make improvements are:

• Consider making all staff aware of the practice’s vision for patient care.

Dr Rosie Benneyworth MB BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.