The Care Quality Commission
  • Doctor
  • GP practice

Archived: Merton Surgery

Overall: Inadequate read more about inspection ratings

Merton Street, Longton, Stoke On Trent, Staffordshire, ST3 1LG (01782) 322966

Provided and run by:
Merton Surgery

All Inspections

27/11/2018 & 13 December 2018

During a routine inspection

We carried out an announced comprehensive inspection at Merton Surgery on 27 November 2018 and an unannounced inspection on 13 December 2018.

The announced inspection was part of our inspection programme and to follow up on the findings of our inspection on 4 December 2017 when the practice was rated requires improvement for providing well led services.

During the inspection on 27 November 2018 the Care Quality Commission contacted external stakeholders to alert them of the serious concerns found. Following the inspection, the external stakeholders attended the practice and put measures in place to ensure safe continuity of care and treatment for patients. The further inspection visit on 13 December 2018 was to establish if our findings from the 27 November 2018 had been acted on in respect of identified patient risks.

We based our judgement of the quality of care at this service 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

We have rated this practice as inadequate overall.

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

  • The management of safety systems was not effective particularly in relation to safeguarding, infection control, employment checks and health and safety risk assessments.
  • Infection Prevention and Control processes had not been adequately applied.
  • Risk assessments relating to how patients and staff would be protected in the absence of assessment of staff immunity against health care acquired infections were not present for all members of staff.
  • We found specific instances where care and treatment had not been provided in accordance with best practice guidelines. We identified examples where diagnoses had been missed, putting patients at risk.
  • The systems, processes and practice that help to keep patients safe and safeguarded from abuse were insufficient. The system in place at the practice had not always ensured that all children who did not attend their appointment following referral to secondary care were appropriately monitored and followed up. There was no list of vulnerable adults or a register for the practice to refer to.
  • Risks associated with blank prescription form security and management had not been considered in respect of home visits and serial number logs.
  • The management of patient medicine reviews was not always effective or documented within the patient records sampled.
  • The management of emergency or high-risk medicines, repeat prescriptions and vaccines did not always promote the safety of patients. The analysis and responses to Medicines and Healthcare products Regulatory Agency (MHRA) alerts were not consistently applied. A risk assessment had not been carried out in respect of emergency medicines not held at the practice.
  • Some staff recruitment checks did not meet legal requirements.

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

  • There was limited monitoring of the outcomes of patient care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • The practice was unable to show that it always obtained consent to care and treatment.

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

  • The practice had no active patient participation group.
  • There were gaps in the practice’s governance systems and processes and the overall governance arrangements were ineffective.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care. There was no leadership in place to drive required improvements.
  • Staff had not completed all required training, some could not recall when they last had an appraisal and there was no oversight of the maintenance of accurate records of skills, qualifications and training for staff.
  • The practice had not developed a sustainable practice business plan or strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice consultation records we reviewed did not always provide appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation. When incidents happened, the practice investigated but there was an absence of fully documented and embedded learning from events.

These areas affected all population groups so we rated all population groups as inadequate.

We rated the practice as good for providing caring services because:

  • Staff involved and treated patients with compassion, kindness, dignity and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing a responsive service because:

  • Most patients found the appointment system easy to use and reported they were able to access care when they needed it.
  • The facilities and premises were appropriate for the services delivered with some exceptions. For example, there was no lowered desk to enable ease of access for wheelchair users or automated doors to maintain patients’ independence in accessing the premise.
  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example electronic alerts on some of the records we reviewed. However, records we looked at confirmed there were gaps in this process and the risks had not been mitigated by following up some patients who had attended A&E.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • There was little information to review regarding learned lessons from individual concerns and complaints or analysis of trends to improve the quality of care.
  • The complaint policy and procedures were in line with recognised guidance. There was however no evidence seen of an acknowledgement of complaint letters or a final letter outlining the outcomes of the investigation and next steps they may choose to take.
  • The practice was taking steps to forge links with the voluntary sector.

Immediately following these inspections, the provider submitted an application to the Care Quality Commission (CQC) to be removed from the CQC provider register. The Clinical Commissioning Group, NHS England and the CQC continue to work together and a supportive framework has been established to ensure patients receive uninterrupted GP services with another CQC registered GP practice.

Had the practice remained registered we would have required them to make the following improvements as they were in breach of regulations:

  • Ensure care and treatment is provided in a safe way to patients.

  • Ensure patients are protected from abuse and improper treatment.

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

  • Ensure specific information is available for each person employed.

In addition the provider would have been placed in Special Measures.

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

4 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Merton Surgery on 18 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 18 August 2016 inspection can be found by selecting the ‘all reports’ link for Merton Surgery on our website at www.cqc.org.uk.

Following the comprehensive inspection on 18 August 2016, we carried out an announced focused inspection on 15 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our comprehensive inspection on 18 August 2016. We continued to rate the practice overall as requires improvement, however the rating for providing effective services had improved to Good.

We carried out an announced focused inspection on 4 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 15 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The reporting and recording of significant events had been reviewed and was sufficiently detailed to show that concerns identified were appropriately followed up to prevent further occurrences and ensure improvements made where appropriate.
  • Arrangements were in place for sharing external patient safety alerts, best practice guidance and the learning outcomes from significant events, incidents and near misses with staff.
  • The practice had implemented a child protection register and alerts were placed on the clinical system to identify children at risk. A protocol had been developed and implemented to monitor and follow up children who did not attend hospital appointments.
  • The practice had reviewed and updated their recruitment policy and had since obtained the required documentation for the main locum GP that was used to provide holiday cover. The practice was in the process of obtaining outstanding documents for another locum GP that they rarely used.
  • Disclosure and barring (DBS) checks had been obtained for all staff that chaperoned. Risk assessments had also been undertaken for existing non clinical staff that did not chaperone but had been employed by the practice for a number of years.
  • Systems to assess, monitor and manage risks to patient safety had improved.
  • The practice had started to improve their governance arrangements, however ongoing improvements were needed to evidence these can be sustained in addition to strengthening the practice management arrangements currently in place. The NHS England Supporting Change in General Practice team were also providing support to the practice

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Continue to review and improve their governance and practice management arrangements currently in place.

  • Review and reconcile the list held of children on the child protection register with external agencies to ensure they are current.

  • Include significant events, safeguarding and complaints as standing agenda items for discussion at practice meetings.

  • Ensure significant events are documented and investigated at the earliest opportunity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Merton Surgery on 18 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 18 August 2016 inspection can be found by selecting the ‘all reports’ link for Merton Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice continues to be rated Requires Improvement.

Our key findings were as follows:

  • Arrangements for identifying, recording and managing risks had improved but were not always effective.

  • Significant events had been actioned but not consistently recorded.

  • The provider had carried out a fire risk assessment to minimise the risks to patients in the event of a fire. However, fire tests were not being carried out.

  • The provider had carried out a legionella risk assessment to minimise the risk of infection to staff and patients. (Legionella is a bacterium which can contaminate water systems in buildings).

  • The provider had obtained appropriate emergency medicine to treat possible complications associated with the insertion of specific intrauterine contraceptive devices.

  • Some improvements had been made in the recruitment of new staff. However, not all of the required documentation had been obtained.

  • The cleaning schedule had been extended to include non-clinical areas of the premises.

  • A system to track prescriptions had been introduced to monitor their use. The practice had moved to the electronic prescription service (EPS), allowing prescriptions to be sent directly to pharmacies electronically.

  • The provider had updated the business continuity plan to include current arrangements but not staff contact details.

  • The provider had reviewed the arrangements of formalised meetings with other healthcare professionals to ensure coordinated patient care was maintained.

  • Patient consent was recorded in accordance with nationally recognised guidelines.

  • Most staff had received an appraisal of their work.

  • Staff felt supported in their work by the management team and felt partners were open and approachable.

  • Governance arrangements were not sufficient to ensure effective governance within the practice.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Complete recruitment checks in accordance with schedule three of the Health and Social Care Act 2008 (Regulated Activities).

  • Complete a risk assessment or criminal records check for all staff who chaperone.

  • Introduce effective processes for ensuring all significant events, incidents and near misses are recorded, discussed and audited to maximise learning.

  • Implement a consistent system to review, discuss and act on patient safety alerts.

In addition the provider should:

  • Review and improve governance arrangements within the practice.

  • Ensure clinical meetings include discussions and actions taken to address safety incidents (significant events, complaints, NICE guidelines etc.).

  • Update the register of vulnerable children in conjunction with external agencies and implement a system to monitor and follow up children who do not attend hospital appointments.

  • Consider a documented business plan to support the practice vision and future strategy.

  • Include staff contact details in the business continuity plan.

  • Undertake a regular analysis of significant events and complaints to identify and evaluate any trends.

  • Review policies and procedures to ensure they are in place and are relevant to the practice, to include a policy for significant events, recruitment and health and safety.

  • Carry out tests on the fire system and emergency lighting system at the required frequency.

  • Document and date completed actions in relation to the legionella risk assessment.

  • Consider holding more regular practice and clinical meetings.

  • Ensure all staff receive training in information governance at the earliest opportunity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Merton Surgery on 18 August 2016. Overall the practice is rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the Care Quality Commission (CQC) at that time.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses.
  • Risks to patients and staff had been identified but not all had been assessed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Clinical staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients spoke of a high level of service that was supported by the national patient survey scores for aspects related to care.
  • Information about services and how to complain was available and easy to understand.
  • Patients told us they could get an appointment when they needed one. Urgent appointments were 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 but the combined role of medical secretary and practice manager impacted the capacity to manage the administration.

The areas where the practice must make improvements are:

  • Ensure risk is assessed in the absence of emergency medicine associated with minor surgery and fitting specific contraceptive devices.
  • Complete recruitment checks in accordance with schedule three of the Health and Social Care Act 2008 (Regulated Activities).
  • Complete a risk assessment or criminal records check for all staff who chaperone.
  • Improve the health and safety procedures to minimise risks to staff and patients. This should include legionella and fire risk assessments.

The areas where the practice should make improvements are:

  • Extend the cleaning schedule to include non-clinical areas of the premises.
  • Introduce a prescription tracking system.
  • Update the business continuity plan to include current arrangements and contact details.
  • Review the arrangements of formalised meetings with other healthcare professionals to ensure coordinated patient care is maintained.
  • Ensure patient consent is recorded in accordance with nationally recognised guidelines.
  • Complete regular appraisals for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice