Archived: Stonecross and West Drive Surgery

We carried out an announced comprehensive inspection at Stonecross and West Drive Surgery on 13 and 14 August 2019. The overall rating for the practice was Requires Improvement.

After our inspection in August 2019 the provider 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 focussed inspection at Stonecross and West Drive Surgery on 11 August 2021 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in August 2019. The practice was rated Inadequate overall and placed into special measures as a result of this inspection. We found that the provider had not made sufficient improvement and issued Warning Notices.

We carried out an announced focussed inspection at Stonecross and West Drive Surgery on 19 November 2021 to confirm that the provider had taken action to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in August 2021. The practice was not rated as a result of this review. We found that the provider had made sufficient improvements and had met the Warning Notices.

The full versions of the reports for the August 2019, August 2021 and November 2021 inspections can be found by selecting the ‘all reports’ link for Stonecross and West drive Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection:

We carried out an announced comprehensive inspection at Stonecross and West Drive Surgery on 1 and 5 April 2022 to confirm that the practice was continuing to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in August 2021. This report covers findings in relation to those requirements.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using the telephone / video conferencing.
• Requesting evidence from the provider.
• A short site visit.

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.

Our findings:

This practice remains 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? – Requires Improvement

Are services well-led? – Inadequate

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

• The provider had not made sufficient improvements to systems, practices and processes in order to keep people safe.
• Improvements to infection prevention and control were still required.
• Risks to patients, staff and visitors were still not always assessed, monitored or managed effectively.
• The provider had not made sufficient improvements to arrangements for managing medicines in order to keep patients safe.
• Systems for dealing with safety alerts were still not always effective.

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

• Patients’ needs were not always assessed, and care as well as treatment were not always delivered in line with current legislation, standards and evidence-based guidance.
• Patients with long-term conditions were not always receiving relevant reviews that included all elements necessary in line with current best practice guidance and not all patient reviews that we looked at were followed up where necessary in a timely manner.
• The practice did not have an effective programme of quality improvement activity that routinely reviewed the effectiveness and appropriateness of the care provided.
• Performance relating to child immunisations and cervical screening had deteriorated.
• All staff were not up to date with essential training and we could not be sure that all staff had access to regular appraisals.
• Staff were not always consistent and proactive in helping patients to live healthier lives.

We rated the practice as Requires Improvement for providing caring services because:

• Patients were not always given appropriate and timely information to cope emotionally with their care, treatment or condition.
• Staff did not always communicate with patients in a way that helped them to understand their care, treatment and condition, and any advice given.

We rated the practice as Requires Improvement for providing responsive services because:

• The practice organised and delivered services but these did not always meet patients’ needs.
• People were not always able to access care and treatment in a timely manner as insufficient nursing staff were employed in order to meet patients’ needs.
• Staff told us that they were not aware of the latest published results from the national GP patient survey and there were no formal plans to improve patient satisfaction scores.

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

• Whilst leaders were compassionate, they were not aware of all required improvements to quality, safety and performance.
• Processes and systems that supported good governance and management were still not always effective.
• The practice’s processes for managing risks and issues still required improvement.
• Processes to manage current and future performance were still not sufficiently effective.
• The practice acted on appropriate and accurate information. However, not all patient records were held securely.
• Clinical audit activity did not always demonstrate quality improvement.

The areas where the provider must make improvements are:

• 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 their duties.

This service was placed in special measures in August 2021. There have been limited and insufficient improvements in the safety and quality of the service such that there remains a rating of inadequate for safe, effective and well-led. I am placing the service into special measures for a further six months.

Services placed into special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any 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 could lead to cancelling their registration or 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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Rosie Benneyworth BM 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.