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Inspection Summary


Overall summary & rating

Inadequate

Updated 2 August 2019

We carried out an announced comprehensive inspection at Higham Ferrers Surgery on 3 December 2018. The overall rating for the practice was inadequate and the practice was placed in special measures.

From the inspection in December 2018 the practice was told they must:

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

In addition, the practice was told they should:

  • Develop mechanisms to share learning from investigations including significant events with the wider team.
  • Develop a replacement/maintenance plan for carpeted floors.
  • Develop plans to engage with the Patient Participation Group (PPG).

The full comprehensive report on the December 2018 inspection can be found by selecting the ‘all reports’ link for Higham Ferrers Surgery on our website at .

This inspection was an announced comprehensive inspection carried out on 19 June 2019, to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 3 December 2018. Prior to the December 2018 inspection the practice had been rated as requires improvement in April 2018. The practice had failed to make the required improvements following the April 2018 inspection which led to the practice being rated as inadequate and placed into special measures in December 2018.

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. The overall rating for this practice is inadequate due to concerns in providing safe and well-led services.

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

  • We found one member of staff who had not been safely recruited.
  • The practice did not have an adequate system in place to safely manage MHRA and other safety alerts.
  • High risk medicines monitoring was not effective and did not ensure patient safety.
  • Prescriptions were not being logged and monitored.

We rated the practice as requires improvement for providing effective, caring and responsive because:

  • Care and treatment was not being effectively delivered due to issues with high risk medicine monitoring and prescribing.
  • The practice had not made the changes it needed to in order to respond to the needs of the patients who used the practice.
  • Patient feedback had not been fully considered or addressed in order to improve the practice for patients.

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

  • The lack of consistent practice management presence was impacting on the quality of care and treatment.
  • Although we found the practice to be improved since our last inspection, we did not yet have evidence that the improvements would be sustainable over time.

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.

This practice was placed in special measures on 22 January 2019. Insufficient improvements have been made such that there remains a rating of inadequate for the safe and well led domain. Therefore the practice will remain in special measures and kept under review. Another inspection will be conducted within six months to ensure the required improvements have been made. If the required improvements have not been made we will take action in line with our enforcement procedures.

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

Inspection areas

Effective

Requires improvement

Caring

Requires improvement

Responsive

Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement