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We are carrying out a review of quality at West Street Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 20 Jan 2020

During a routine inspection

The service is rated as Good overall.

We carried out an announced comprehensive inspection at West Street Surgery on 27 January 2020 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation.

The practice received an overall rating of inadequate at our inspection on 20 September 2019 and 22 May 2019 and warning notices were issued.

The full comprehensive report from the September 2019 and May 2019 inspection can be found by selecting the ‘all reports’ link for West street Surgery on our website at .

Our judgement of the quality of care at this service is based 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.

The practice is rated a

s good overall.

(previously rated as inadequate in May 2019)

Key findings:

  • The practice was compliant with the warning notices issued in May 2019.
  • People who used the service were protected from avoidable harm and abuse, and requirements were met. Staff had a good understanding of how to escalate concerns.
  • There was effective audits and risk assessments in place in relation to fire, legionella, health and safety and infection prevention and control. Actions required were being completed.
  • There was effective management of medicines and prescribing including for medicines that required additional monitoring.
  • There was good oversight of pathology results and clinical practice. The practice had conducted clinical competency assessments and mentoring sessions that fed into individual appraisals.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • Patients’ needs were met by the way in which services were organised and delivered.
  • Concerns raised regarding access to the practice via the telephone were being addressed by the introduction of an improved telephone system.
  • The practice delivered person-centred care and communicated effectively with community teams. They were flexible to the needs of the most vulnerable and complex patients.
  • The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
  • Regular staff meetings were held to ensure communication was clear and effective.
  • Staff were proud to work at the practice and were supported with their personal and professional development.

The area where the provider should make improvements are:

  • Continue to monitor and improve child immunisation uptake.
  • Continue to monitor and cancer screening and care planning uptake.
  • Continue to monitor and improve levels of patient satisfaction regarding lower than average indicators.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 22 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at West Street Surgery on 22 May 2019 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation when they were placed in special measures.

The practice received an overall rating of inadequate at our inspection on 19 September 2018 when warning notices were issued. The practice was inspected on 27 February 2019 and found to be compliant with the warning notices.

The full comprehensive report from the September 2018 and February 2019 inspection can be found by selecting the ‘all reports’ link for West Street Surgery on our website at .

Our judgement of the quality of care at this service is based 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.

The practice is rated as Inadequate overall.

(previously rated inadequate in September 2018)

We rated the service as requires improvement for providing Safe services because:

  • Systems had been implemented to assess risk, however, these were not always effective and there was evidence that remedial work had not been completed.
  • The practice had improved the oversight of significant events, learning and complaints however, these did not always lead to quality improvements.
  • Fire extinguisher checks had not been completed.
  • Health and safety audits and an infection prevention and control audit had been completed.

We rated the service as inadequate for providing Effective services because:

  • Limited numbers of care plans had been completed for those in vulnerable groups such as those suffering from a mental health condition or with a cancer diagnosis.
  • There was a limited numbers of health checks being offered to eligible patients.
  • There was high exception reporting in some areas.
  • There was oversight of staff training needs and all training required by the provider had been completed however, there were gaps in additional GP training such as mental capacity act training.

We rated the service as requires improvement for providing Caring services because:

  • The practice had commenced a carers register however, it had low numbers with less than 0.5% of the practice population being identified as carers.
  • We saw evidence of staff treating patients with kindness and compassion.
  • Patients told us staff were helpful and they felt involved in their treatment plans.

We rated the service as inadequate for providing Responsive services because:

  • There was oversight of complaints and these were shared with staff, however, there was no evidence of what actions had been completed to improve practice and no evidence of learning shared with the wider team.
  • There was no evidence of actions taken or improvements made following the GP patient survey results.
  • Patients and staff told us that GP sessions regularly started up to an hour late.

We rated the service as inadequate for providing Well-led services because:

  • The practice had unclear governance and management structures.
  • Some staff told us they felt undervalued and demotivated due to the disorganisation of the management team.
  • Staff told us that communication had improved but was still not sufficient.
  • Key changes to systems, policies and procedures were not communicated with staff.

The areas where the provider must make improvements as they are a breach of regulation 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.

There were areas where the provider should make improvements are:

  • Continue to proactively identify carers and offer appropriate support.

This service was placed in special measures in December 2019. Some improvements have been made however insufficient improvements have been made in some areas. Therefore, the service will remain in special measures for a further six months. 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 act in line with our enforcement procedures to begin the process of preventing the provider from operating the service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 27 Feb 2019

During an inspection looking at part of the service

We carried out an announced focused inspection of West Street Surgery on 27 February 2019. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation set out in warning notices we issued to the provider in relation to Regulation 12 Safe care and treatment and Regulation 17 Good governance.

The practice received an overall rating of inadequate at our inspection on 19 September 2018 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full comprehensive report from the September 2018 inspection can be found by selecting the ‘all reports’ link for West Street Surgery on our website at .

Our key findings were as follows:

  • The practice had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • The practice had conducted risk assessments for fire and health and safety and had plans for completing any actions identified.
  • The practice had developed logs for complaints, significant and safety alerts and these were shared with practice staff at clinical meetings.
  • The practice had improved infection control practices.
  • The practice had developed a training matrix to maintain oversight of staff training needs. Most staff had completed mandatory training.
  • The practice had begun a programme of staff appraisal where clinical competence was assessed and evaluated.
  • Staff told us that they felt more supported however some staff still felt undervalued.
  • Communication between the management and staff teams had improved however reception staff had not been included in meetings.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 19 Sept 2018

During a routine inspection

This practice is rated as inadequate overall.

(Previous rating November 2016 – Good)

The key questions 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 carried out an announced comprehensive inspection at West Street Surgery on 19 September 2018, under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was carried out in response to concerns raised regarding the leadership at the practice. The full comprehensive report on the September 2018 inspection can be found by selecting the ‘all reports’ link for West Street Surgery on our website at

www.cqc.org.uk

.

At this inspection we found:

  • The practice had ineffective systems to manage risk. When incidents did happen, the practice did not share learning from them or improve their processes.
  • There was a lack of oversight of complaints, significant events and safety alerts. This led to a lack of learning from these events.
  • Not all staff had completed the required mandatory training.
  • There were ineffective processes around safeguarding of vulnerable adults and children. Not all staff had received safeguarding training.
  • There were gaps in the system used for prescribing certain high risk medicines. The practice could not provide evidence to assure us that blood test results were always reviewed prior to prescribing.
  • Staff immunisations were not recorded for both clinical and non-clinical staff.
  • We found gaps in record keeping to support appropriate monitoring of the cold chain, as vaccination fridge temperatures were not consistently recorded.
  • Not all patients had care plans recorded on the system to assess their medical condition where appropriate.
  • Staff did not always feel supported, regular appraisals and training were not carried out. There were poor communication structures within the practice.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the latest National GP Patient Survey showed patients were satisfied with their interactions with reception staff and consultations with GPs and nurses.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.

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.
  • 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:

  • Proactively identify carers and ensure they are given appropriate support.

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 FRCGPChief Inspector of General Practice

Inspection carried out on 6 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West Street Surgery on 6 July 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed. However we found that the practice had not always updated patient records with monitoring information when they received high risk medications.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Continue to monitor the recently implemented protocol to ensure children who fail to attend a hospital appointment (DNA) are easily identified and acted on.

  • Ensure a system is implemented to ensure that all monitoring results of patients receiving repeat high risk medications are recorded within patient records.

  • Continue to monitor the recently introduced communication pathway to the out of hours provider (OOH) to keep them informed of specific patients who may need care outside of normal practice hours and at weekends.

  • Continue to monitor and act on the results of the national patient survey.

  • Improve record keeping in relation to complaints to ensure verbal communication with complainants is recorded in the complaints file.

  • Continue to identify and support carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice