Northfield Surgery

Updated 24 August 2023

Northfield Surgery is located in the Thorne area of Doncaster at:

The Vermuyden Centre

Thorne

Doncaster

DN8 4BQ

The practice has additional unregistered locations.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the NHS South Yorkshire Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 9940 patients. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called the Doncaster East Primary care Network (PCN).

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the third lowest decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 1.8% non-white ethnic groups.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of 2 GP (male) partners as well as 5 long-term locum GPs (4 female and 1 male). The practice has a team of 1 physician associate (PA), 1 nurse practitioner (NP) and 4 practice nurses who support the GPs in the delivery of services. The clinical team are supported at the practice by a team of reception and administration staff. The practice manager and patient experience manager are based at the main location.

The practice is open between 8 am to 6 pm Monday to Friday, with the exception of Tuesdays when the surgery is open until 8.30 pm. The practice offers a limited range of appointment types including book on the day and advance face to face appointments. They do not offer online of telephone consultations.

Extended access is provided locally by the PCN, where Saturday appointments are available from 8 am until 1 pm. Out of hours services are provided by NHS 111.

Updated 24 August 2023

We carried out an unannounced comprehensive inspection at Northfield Surgery on 25 May 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 15 January 2018, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Northfield Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this comprehensive inspection in response to risk following receipt of information of concern.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A single day site visit.

Our findings

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 found that the practice:

• Was unable to demonstrate that safe systems or practices were in place or working effectively in relation to medicines management, safeguarding, recruitment, or the management of risks to patients or staff.
• Was unable to demonstrate that action taken to address below target uptake for childhood immunisation and cervical screening had led to any improvements in these data. Additionally, the practice was unable to demonstrate that patients’ needs were always met, that staffing was effective or that they had actively engaged in joined up working.
• Was unable to demonstrate that they had taken action to address poor satisfaction of patients who responded to the GP patient survey, or those patients in their internal survey that were less satisfied than others. They were also unable to demonstrate that a carers register was in place or was being used to provide caring services for those patients.
• Was unable to demonstrate that they had taken appropriate actions to address lower areas of satisfaction from patient feedback or to demonstrate that any actions had been taken to record or address complaints. Furthermore, we saw that there was a decline in patient satisfaction over time in previous surveys and there was no system in place to address this.
• Systems and process in place were not working as intended, overseen effectively or structured in a way that enabled the provider to fulfil their responsibilities to the practice population. Clinical and non-clinical leadership were unable to demonstrate adequate capacity to deliver high-quality or fully safe services which had led to significant gaps throughout the service.

We found breaches of regulations. The provider must:

• 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 provider should also:

• Take steps to address low uptake in cervical screening and childhood immunisations.
• Review all areas of patient satisfaction survey data and address concerns raised.
• Ensure vulnerable patients including all carers, all people with a learning disability and other vulnerable patients are identified and appropriately supported.

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

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 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 Sean O’Kelly BSc MB ChB MSc