Archived: The Beggarwood Surgery

Letter from the Chief Inspector of General Practice

At our previous inspection in February 2017 we found the practice to be inadequate overall. Following this inspection on 14 November 2017 we rated the practice as requires improvement overall.

The key questions are rated as:

• Are services safe? – Requires improvement

• Are services effective? – Requires improvement

• Are services caring? – Good

• Are services responsive? – Requires improvement

• Are services well-led? -Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. Due to the overall rating being Requires Improvement the population groups are rated as:

• Older People – Requires improvement

• People with long-term conditions – Requires improvement

• Families, children and young people – Requires improvement

• Working age people (including those retired and students) – Requires improvement

• People whose circumstances may make them vulnerable – Requires improvement

• People experiencing poor mental health (including people with dementia) - Requires improvement

Previously we undertook a follow up comprehensive inspection of The Beggarwood Surgery on 28 February 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as inadequate and placed into special measures. Warning notices were also served. We then undertook a follow up, focused inspection on 21 June 2017 to look specifically at the shortfalls identified in the warning notices. We found that there were some improvements at that time.

On this occasion we carried out an announced comprehensive inspection at The Beggarwood Surgery on 17 November 2017, to follow up on breaches of regulations found at our comprehensive inspection in February 2017 as well as progress since the inspection in June 2017.

At this inspection we found:

• The practice had recently introduced new systems to manage risk so that safety incidents were less likely to happen. When incidents were identified, the practice learned from them and improved their processes.

• The practice had recently commenced routine reviews of the effectiveness and appropriateness of the care it provided.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• The practice had recently employed a clinical lead GP to improve local clinical oversight.

• There was an increasing availability of both urgent and routine appointments.

• The practice had a vision of improvement, although there was no yet a sustained track record for delivery of the vision.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

This service was placed in special measures in June 2017. Insufficient improvements have been made such that there remains a rating of inadequate for 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 focused inspection at The Beggarwood Surgery on 21June 2017. This was to check on improvements relating to the serious concerns found during a comprehensive inspection on 28 February 2017. The first inspection had resulted in the Care Quality Commission issuing warning notices with regard to Regulation 17 (Good Governance) and Regulation 18 (Staffing).

In February 2017 the practice was rated as inadequate overall and was placed into special measures. Specifically the domains of safe and well-led were found to be inadequate, with the domains of effective, caring and responsive rated as requires improvement.  The full report for the February 2017 inspection can be found by selecting the ‘all reports’ link for The Beggarwood Surgery on our website at www.cqc.org.uk.

At this inspection in June 2017, we checked the progress the provider had made to meet the significant areas of concern as outlined in the warning notices. We gave the provider until the 26 May 2017 to rectify these concerns. The warning notices were issued because we found that there were inadequate systems and processes in place to provide safe, high quality care.

At our inspection on 21 June 2017 we found that the provider had made some improvements However, there were still areas relating to these warning notices that required further improvement.

Our key findings were:

• Governance and leadership systems remained unclear at practice level. At the time of inspection, there were no confirmed plans in place regarding how the clinical lead role would be fulfilled, however remote clinical leadership was in place.

• There remained no registered manager at the practice, however an application was made following the inspection. There was managerial support from the provider organisation.

• All permanent GPs and the advanced nurse practitioner had left since our last inspection or were due to be leaving the practice by July 2017.

• Locum GP and Nursing staff had been recruited in the short term while recruitment for permanent staff was being undertaken.Locum staff were evidenced to be covering the clinical session requirements for the practice.

• There was a comprehensive induction process for locum staff and this was in the process of being improved by the practice management.

• There were no formal or informal clinical meetings with the locum staff.

• There was a lack of clinical supervision systems for staff.

• Training programmes had been delivered but not all training was updated as it should have been according to the practice’s policy.

• Systems had been implemented to ensure that policies were updated and reviewed as required.

• Risk assessments relating to fire and health and safety had been assessed and appropriate actions taken.

• Procedures had been introduced for clinical guidance on high risk medication monitoring.

• There was availability of both urgent and routine appointments.

• The patient participation group were becoming more involved with the practice with the first actual, rather than virtual, meeting taking place together with the practice management.

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.

Two further requirement notices have been issued to the practice in relation to governance and staffing shortfalls.

The ratings from the inspection in February 2017 will remain in place until a further comprehensive inspection is undertaken.

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 The Beggarwood Surgery on 31 May 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for The Beggarwood Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 28 February 2017. Overall the practice is now rated as inadequate.

Our key findings were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example fire risk assessments had identified actions that had not been acted upon. Not all staff were up to date with safeguarding training and staff were unaware of the chaperone policy in place in the practice.

• Although the emergency medicines and equipment were present in the practice there were some members of staff who did not know where they were located.

• Provision of additional medicines was undertaken without it being demonstrated that there was an adequate review of their care or treatment.

• National drug alerts were not being communicated effectively to all clinical staff.

• The majority of patients felt that they were treated with compassion and caring by the clinical staff. However they also felt that the staff seemed stressed and that routine appointments were difficult to obtain.

• The practice did not demonstrate effective leadership at local level. Staff felt that they were not involved with the management of the practice and that communication to the practice staff was poor.

• Practice policies and protocols were reviewed, but sometimes not in a timely manner.The policies were not always adapted to local practice level, and therefore were not always relevant.

• Staff were not having regular appraisals and some mandatory training was not up to date.

• There was a shortage of staff with some GPs having to cover vacancies at another practice.This was resulting in a reduction of clinical sessions available to patients.Some staff expressed that the practice was now clinically unsafe due to staff shortages and GPs had reported their concerns to the local clinical commissioning group.

• There were some comprehensive care plans in place for patients, although not all of these were evidenced to be on the patients’ electronic records and therefore were not necessarily easy to access.

• There was a high level of patient screening for disease and childhood immunisation rates were higher than the national averages.

• There was some opportunistic screening of patients for diabetes and respiratory diseases.

• There was a good system for dealing with complaints.

• The premises were clean and tidy with relevant cleaning checklists in place and there was an infection control lead undertaking cleaning audits.

Importantly, the provider must:

• Ensure that they operate effective systems and processes in order to assess and monitor the service that they provide.

• Ensure that suitable policies are in place to make sure that safety information (including MHRA drug safety alerts) are acted upon and communicated to all staff.

• Ensure that patients on high risk medicines are reviewed and monitored adequately.

• That all policies are up to date with the relevant information for the practice and that there are policies in place for all management requirements.

• Ensure procedures for assessing risk, and following risk assessments, are actioned; for example fire recommendations and provision of chaperone services.

• Ensure information is kept up to date, is accurate, and is properly analysed to ensure that where needed it is escalated and appropriate action is taken.For example, to ensure the sharing and escalation of significant event reporting and review these events for trends and analysis.

• Ensure all staff are aware of emergency policies and procedures – for example where the emergency equipment is stored in the practice.

• Ensure that the practice is actively encouraging feedback about the quality of care from all relevant persons, including patients, patient carers, staff and other relevant bodies. All feedback should be recorded and responded to as appropriate in order to evaluate and improve the service.

• Ensure that the practice has adequate staff for both urgent and routine appointments.

In addition the provider should:

• Review procedures for routine appointments as many patients feel that they are often unable to make suitable appointments.

• Review care planning integration with patient records.

• Review the number of staff meetings so that staff have more communication with management.

• Review the role of the patient participation group (PPG) and their role within the practice.

• Support staff to obtain further appropriate qualifications that enable them to perform their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice