Archived: Hornsey Park Surgery Also known as Hornsey Park Surgery Trust

We previously carried out an announced comprehensive inspection at Hornsey Park Surgery on 30 May 2019 and 3 June 2019. Overall the practice was rated as inadequate and placed into special measures.

We identified concerns in regard to whether the service was safe, effective, caring, responsive and well-led. We served warning notices under regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice was required to address these concerns by 17 September 2019.

The full comprehensive report on the inspection which took place on 30 May and 3 June 2019 can be found by selecting the ‘all services’ link for Hornsey Park Surgery on our website at https://www.cqc.org.uk/.

The practice sent us a plan of action to ensure the service was compliant with the requirements of the regulations.

We carried out this focussed inspection on 26 September 2019, to review the practice’s action plan, looking at the identified breaches set out in the warning notice, under the key questions of Safe and Well-led. We found the practice had made improvements sufficient for us to consider the warning notices had been met.

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.

We have not reviewed the ratings for the key questions or for the practice overall as this is a focussed follow-up inspection to look at whether the Warning Notices served under the Safe and Well-led key questions have been met.

We will consider the practice’s ratings in all key questions and overall when we carry out a full comprehensive inspection at the end of the period of special measures.

We found the provider had made sufficient improvement in providing safe services because:

• Action had been taken since our last inspection such that reliable systems were now in place to prevent and protect people from a healthcare-associated infection (for example, an Infection Prevention and Control (IPC) audit had now taken place and staff had acted on findings. A risk assessment had now also taken place regarding a bacterium called Legionella which can proliferate in water systems. Appropriate eye protection was now also available and other personal protective equipment such as aprons were readily accessible).
• Appropriate arrangements for managing waste were now in place (for example, sharps bins at the practice were now appropriate for the procedures being undertaken and clinical waste was now labelled with practice details).
• Arrangements for managing medicines now kept people safe (for example, staff were now routinely ensuring uncollected prescriptions were being monitored and that emergency medicines were appropriate, regularly checked and easily accessible. We also saw evidence the lead GP routinely ensured the prescribing competence of the practice's advanced nurse prescriber).
• Systems were now in place to ensure learning from incidents was shared and used to improve patient safety (for example, records confirmed that regular team meetings took place where incidents were reviewed and learning was shared).

We found the provider had made sufficient improvement in providing well led services because:

• Practice management and governance arrangements now promoted the delivery of high-quality, person-centred care. Appropriate medicines management governance arrangements were now in place (for example uncollected prescriptions were being monitored in accordance with the practice’s protocol and infection risks were now being comprehensively audited and acted upon).
• Appropriate governance arrangements were in place to ensure the practice was now working in accordance with its own safeguarding protocol regarding staff pre-employment checks.
• Clinicians with whom we spoke were aware of the practice’s high risk medicines protocol document and records confirmed patients were monitored and prescribed high risk medicines in accordance with the protocol.

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 an announced comprehensive follow up inspection at Hornsey Park Surgery on 30 May 2019 and 3 June 2019.

CQC previously inspected the service on 15 November 2018 and asked the provider to make improvements because although the service provided was caring and responsive, it was not being provided in accordance with the relevant regulations relating to safe, effective and well led care. Specifically, we found the provider had breached Regulation 17 (1) (Good governance) and Regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008.

This was because the provider did not have a formal written protocol in place for acting on patient safety alerts or an effective system to manage risks associated with the Legionella bacterium. Also, the provider did not have a written protocol in place in relation to the management of high risk medicines and appropriate pre employment checks were not on file for some staff members.

Two Requirement Notices were served and shortly thereafter the provider wrote to us to tell us how they planned to make improvements. We undertook this comprehensive inspection to check the service had followed their plan and to confirm they had met the legal requirements.

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.

We have rated this practice as inadequate overall.

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

•The practice had not appropriately addressed the Requirement Notice served at our inspection on 15 November 2018, by failing to commission a water sample analysis to check for the presence of the Legionella bacterium. At our 2019 inspection we identified additional concerns relating to the premises which also put patients at risk.

•When things went wrong, the approach to reviewing and investigating causes was inadequate and there was little evidence of sharing learning from events.

•The practice did not have appropriate systems in place for the safe management of medicines as effective arrangements were not in place for either the monitoring or security of prescriptions pads when they were distributed through the practice.

•Staff did not assess, monitor or manage risks to patients who used the services. For example, infection risks were not properly identified or acted upon.

•An absence of clinical leadership support for locum staff increased risks to patients who used the service. For example, the principal GP went on sick leave in March 2019 but interim safeguarding arrangements had not been effectively communicated to staff.

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

•Leaders could not show they had the capacity and skills to deliver high quality, sustainable care. They were out of touch with what was happening during day-to-day services.

•An absence of clinical leadership meant governance arrangements were unclear or out of date.

•The practice did not have clear and effective processes for managing risks, issues and performance.

•We saw little evidence of systems and processes for learning, continuous improvement and innovation.

•There was minimal engagement with patients who used services.

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

•An absence of clinical leadership meant the outcomes of patients’ care and treatment was not monitored effectively, as regular clinical meetings did not take place.

•There was limited participation in multidisciplinary working. The practice did not undertake regular multidisciplinary palliative care case review meetings.

•We did not see evidence that two cycle audits were being used to drive improvements in care and treatment.

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

•We saw limited evidence of actions taken to improve below average patient satisfaction on how staff treated patients with care and concern. Shortly after our inspection the practice sent us its action plan for improving patient satisfaction but this lacked sufficient detail.

We rated all population groups as requires improvement. This was because we were not assured patients’ treatment was being regularly reviewed or that outcomes were being robustly monitored for all population groups.

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

•Access to appointments and services were managed to take account of people’s needs, including those with urgent needs.

•Consequently, patient satisfaction on the type of appointments offered and telephone access were above local and national averages.

•Reasonable adjustments were made and action was taken to remove barriers when people found it hard to use or access services.

•Improvements were made to the quality of care as a result of complaints and concerns.

The areas where the provider must make improvements are:

•Ensure that care and treatment is provided in a safe way.

•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:

•Continue to monitor the effectiveness of the practice’s recently introduced cervical screening ‘failsafe’ system.

•Take action to publicise the practice’s complaints procedure on the practice website.

•Take action to publicise information about patient support groups on the practice web site.

•Ensure the practice’s opening hours are in accordance with it’s NHS contract.

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.

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

This practice is rated as Requires Improvement overall. (Previous rating January 2018 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

We carried out an announced comprehensive inspection at Hornsey Park Surgery on 15 November 2018 to follow up concerns identified at our previous inspection on 10 January 2018.

In January 2018, we rated the practice as Requires Improvement for providing caring services (because national patient survey scores were below local and national averages) and rated the service as Good for providing safe, effective, responsive and well led services. Overall the practice was rated as Good.

At this inspection we found:

• Staff did not always appropriately assess, monitor or manage risks to people who used the service. For example, although a Legionella risk assessment had taken place, the practice had not undertaken the subsequent actions required to mitigate against identified risks.
• We saw evidence patients did not find it easy to raise complaints and when they did, they received an unsatisfactory response.
• Since our last inspection the practice had introduced an action plan to improve patient survey satisfaction scores on the extent to which doctors involved patients in care decisions. Latest comparable patient survey results showed that performance was still below local and national averages but we noted the survey took place only two months after the action plan’s introduction and therefore improvement activity might not yet have positively impacted on patient satisfaction scores.
• Patients told us that staff were kind, respectful and compassionate.

• Governance arrangements did not always operate effectively. The practice’s recruitment policy did not list staff pre-employment checks and the absence of a protocol for managing patient safety alerts meant roles and responsibilities were not clearly understood. Also, monitoring of patients on high risk medicines was not governed by a written protocol to ensure it was safe, timely and in accordance with best practice guidelines.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

• Review protocols for ensuring that periodic defibrillator checks take place.
• Review arrangements for following up failed children’s appointments.
• Review arrangements for identifying patients with dementia.
• Review arrangements to improve cancer screening uptake rates.
• Review arrangements for developing and supporting Patient Participation Group led patient surveys.
• Review arrangements for managing complaints.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice