Archived: Elmdene Surgery

Updated 7 January 2019

Updated 7 January 2019

This practice is rated as inadequate. (The practice was previously inspected in June 2016 and was rated as good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Inadequate

We carried out an announced responsive comprehensive inspection at Elmdene Surgery on 12 July 2018 in response to changes at the practice and concerns. For example, one partner left the practice in May 2018, two complaints have been received by CQC in quick succession regarding difficulties accessing care and treatment and there has been insufficient management infrastructure for approximately two years.

Elmdene Surgery has experienced significant growth with the registered patient list size growing by 50% in a two year period, from 6000 patients in 2016 to 9100 patients in 2018. The practice has failed to adequately respond to this challenge. There has been insufficient management infrastructure and insufficient leadership capacity and capability. There are significant concerns regarding the two dispensaries at the branch surgeries of this practice, which both lack leadership oversight and governance and do not operate safely.

A warning notice regarding the breach of the Health and Social Care Act 2008, Regulation 17, Good Governance, was served on the practice.

At this inspection we found:

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not consistently learn from them or improve their processes.
• Lack of skilled and qualified management staff increased the risks to people who use services.
• Staff had the information they needed to deliver safe care and treatment to patients.
• The practice did not have reliable systems for appropriate and safe handling of medicines, including in the two dispensaries.
• The practice did not have a comprehensive programme of quality improvement activity and did not consistently review the effectiveness and appropriateness of the care provided.
• Staff had the skills, knowledge and experience to carry out their roles.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients reported that the appointment system was easy to use, but that there were sometimes difficulties in accessing the practice by telephone.
• Leaders did not have the capacity to deliver high-quality, sustainable care.
• The provider was receptive to the findings of the inspection and the lead GP partner was immediately responsive, sending documents to show steps towards mitigation of risk and improvement.

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

• Ensure that there are effective systems and processes established to ensure good governance.
• Ensure that there is sufficiently qualified and experienced management at the practice.

The areas where the provider should make improvements are:

• Review their recruitment policy so that it is in line with regulation.
• Review the lone working procedure for all staff to help mitigate risk.
• Review and improve the support they offer to carers.

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

Updated 14 September 2018

Updated 14 September 2018

Updated 14 September 2018

Updated 14 September 2018

Updated 14 September 2018

Updated 14 September 2018