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High Street Surgery Requires improvement

Reports


Inspection carried out on 17/04/2019

During a routine inspection

We previously carried out an announced comprehensive inspection at the practice on 22 October 2014. The practice was rated as requires improvement overall and for providing safe and well led services. The practice was rated as good for providing effective, caring and responsive services. We carried out a focused inspection on 8 October 2015 and the practice was rated good overall and for providing safe services and requires improvement for providing well led services. We carried out an announced comprehensive inspection on 20 September 2017. The practice was rated as inadequate overall, requires improvement for providing safe services, inadequate for providing effective and well led services and good for providing caring and responsive services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 October 2017 for regulation 17 (good governance) and was placed into special measures for six months. We carried out an announced comprehensive inspection on 12 April 2018. The practice had complied with the warning notice and were taken out of special measures. They were rated requires improvement overall, and for providing safe and well led services and good for providing effective, caring and responsive services. The full comprehensive reports on the 4 October 2014, 8 October 2015, 20 September 2017 and 12 April 2018 inspections can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.

The practice is rated as

requires improvement

overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at High Street Surgery on 17 April 2019. This inspection was to follow up on breaches of regulation identified at the previous inspection and to see if improvements made since the practice was taken out of special measures had been maintained.

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 requires improvement overall. At this inspection we found:

  • The required improvements had been made in relation to health and safety risk assessments and the implementation of fire safety recommendations.
  • Staff dealt with patients with kindness, compassion and respect and involved them in decisions about their care and treatment.
  • A carers lead had been appointed, who organised information and support to carers.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Improvements had been made to the way the practice was led and managed. The leadership was open, and staff were listened to and involved in service developments. A patient participation group had been established and members were involved in improving the service.

We rated the practice as requires improvement for providing safe services because:

  • Medicines and Healthcare products regulatory agency (MHRA) alerts were not always monitored to completion.
  • There was a cervical screening failsafe system in place, however, not all patients had been recorded on the system.

The practice is rated as requires improvement for providing effective services because two population groups, people with long term conditions and people experiencing poor mental health (including people with dementia) were rated as requires improvement. This was because:

  • The exception reporting data for the quality and outcome framework relating to long term condition and mental health indicators, was above the CCG and England averages. Although the practice excepted patients in line with QOF requirements, and some patients had had follow up telephone calls, a significant number of patients had not received the interventions. Some performance had declined since our last inspection.
  • Evidence based guidance was not always followed; we identified some patients on combinations of medicines which were not recommended.

We rated the practice as requires improvement for providing well led services because:

  • The practice did not have an effective system for monitoring performance through accurate data, specifically related to the exception rates for the quality and outcomes framework data. This had been identified at previous inspections and although the unverified 2018 to 2019 data showed some exception reporting had reduced, it did not demonstrate a significant improvement. The practice had provided Ardens exception reporting data, although this did not correlate with the QOF exception reporting data. The practice advised they were not able to address this as they could not access the QOF data, however, this had not been acknowledged until we announced our inspection.
  • Effective processes were not in place to monitor and improve performance, in relation to childhood immunisation and cervical screening. Although the lead nurse audited the uptake of immunisation and wrote to and telephoned patients, the practice performance was below the World Health Organisation target of 90%.
  • Although improvements had been made to prescribing data, for example, the clinical pharmacist had reviewed patients prescribed three different hypnotic medicines, and subsequent audit had identified a decrease in the number of patients prescribed these medicines, the practice data for hypnotic prescribing continued to be significantly above the CCG and England averages.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

The areas where the provider

should

make improvements are:

  • Continue to engage with the Clinical Commissioning group to improve their prescribing.
  • Continue work to improve childhood immunisation and cervical screening uptake rates.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice

Inspection carried out on 12/04/2018

During a routine inspection

This practice is rated as requires improvement overall. At the previous Care Quality Commission (CQC) inspection 20 September 2017, the practice was rated as inadequate overall). Our announced comprehensive inspection on 12 April 2018 was undertaken to ensure that improvements had been made following our inspection carried out in September 2017.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We previously carried out an announced comprehensive inspection at Drs Seehra, Lockyer, Davis and Tanoe on 22 October 2014. The practice was rated as good for providing effective, caring and responsive services and requires improvement for providing safe and well led services. Overall the practice was rated as requires improvement. We carried out a focused inspection on 8 October 2015 and the practice was rated good for providing safe services and requires improvement for providing well led services. Overall the practice was rated as good. We carried out an announced comprehensive inspection on 20 September 2017. The practice was rated as inadequate overall, requires improvement for providing safe services, inadequate for providing effective and well led services and good for providing caring and responsive services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 13 October 2017 for regulation 17 (good governance) and was placed into special measures for six months. The full comprehensive reports on the 4 October 2014, 8 October 2015 and 20 September 2017 inspections can be found by selecting the ‘all reports’ link for Drs Seehra, Lockyer, Davis and Tanoe on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Drs Seehra, Lockyer, Davis and Tanoe on 12 April 2018. This inspection was undertaken following the period of special measures and to check on improvements detailed in the warning notice issued on 13 October 2017, following the inspection on 20 September 2017. Overall, the practice is now rated as requires improvement. The practice is no longer in special measures. At this inspection we found:

  • When incidents happened, the practice learned from them and improved their processes.
  • Not all safety systems were operating effectively including those relating to health and safety and fire safety.
  • Arrangements were in place to keep patients safeguarded from abuse.
  • Appropriate recruitment arrangements were in place.
  • Appropriate arrangements were in place for infection control, although risk assessments for staff who did not have Hepatitis B immunity or where this was not known had not been completed.
  • Staff had received training the practice identified as mandatory.
  • Performance data was in line with local and national averages, however the overall clinical exception reporting for 2016/2017, was significantly above the local and national averages. 2017/2018 unverified data provided by the practice, showed that the overall clinical exception reporting had significantly reduced.
  • The practice performance for prescribing hypnotic medicines and antibiotic medicines was above the Clinical Commissioning Group (CCG) and national averages. The practice met monthly with the CCG medicines team and were working to improve their prescribing.
  • 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 improvements were made to the quality of care as a result of complaints and concerns.
  • Patients were able to get an appointment, although patients reported there could be a wait to see a specific GP. Patients confirmed that urgent appointments were available the same day.
  • The practice obtained and responded to patient feedback. They had an action plan in response to the national GP patient survey, in the areas where their performance was below the clinical commissioning group average. They had worked with Healthwatch Suffolk to obtain patient feedback, and planned to develop a patient participation group.
  • We received mixed comments from staff in relation to the leadership at the practice. All of the clinical staff felt supported and that the clinical leadership had started to improve. However, some of the non-clinical staff we spoke with told us they did not feel supported and did not feel able to raise issues.
  • Governance processes and systems for business planning, risk management, performance and quality improvement had been implemented. These needed to be embedded to ensure they operated effectively.

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.

The areas where the provider should make improvements are:

  • Continue to engage with the Clinical Commissioning Group to improve their prescribing.
  • Continue to improve the identification of carers and provision of information to support carers.
  • Continue to improve the uptake of cervical screening, including screening for patients with a learning disability.
  • Continue with plans to establish a patient participation group to obtain feedback from patients.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 20 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Drs Seehra, Lockyer, Davis and Tanoe on 22 October 2014. The practice was then rated as good for providing effective, caring and responsive services and requires improvement for providing safe and well led services. Overall the practice was rated as requires improvement. We carried out a focused inspection on 8 October 2015 and the practice was rated good for providing safe services and requires improvement for providing well led services. Overall the practice was rated as good. The full comprehensive reports on the 4 October 2014 and 8 October 2015 inspections can be found by selecting the ‘all reports’ link for Drs Seehra, Lockyer, Davis and Tanoe on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Drs Seehra, Lockyer, Davis and Tanoe on 20 September 2017. Overall the practice is now rated as inadequate.

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

  • There was a system for reporting, recording and sharing the learning from significant events, however checks were not made to ensure identified learning had been actioned.

  • A new process had been established so patient safety alerts were logged, shared, initial searches completed and the changes affected. This process needed to be embedded in practice as not all clinicians were aware of it.
  • Arrangements were in place to keep patients safeguarded from abuse. However some information displayed in the practice was out of date. The practice could not evidence that all staff had received safeguarding training applicable to their role. Appropriate recruitment arrangements were in place; however one clinical staff member was still awaiting a Disclosure and Barring Service Check (DBS) and worked unsupervised with patients.
  • Some arrangements were in place for infection control; however we found that policies and procedures needed to be updated, sharps bins were not dated and clinical waste was not stored securely. Identified actions from the infection control audit completed in April 2017 needed to be completed.
  • Health and safety risks to patients and staff were not all assessed, which included legionella. This had been identified and an external company had been booked to undertake this work in November 2017.
  • 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. A new programme of mandatory e-learning was being completed by staff. Not all staff had received an annual appraisal. Some staff we spoke with did not feel supported, although they reported this had improved since the new practice manager had come into post.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, written consent was not obtained for minor surgery and verbal consent was not always documented.
  • Information about services and how to complain was available and improvements were made to the quality of care as a result of complaints and concerns. Checks were not made to ensure identified learning had been actioned.
  • Generally patients were able to get an appointment, although patients reported there could be a wait for the telephone to be answered, especially in the morning. Patients confirmed that urgent appointments were available the same day.
  • The practice lacked effective clinical leadership and they did not have a clear and established governance framework.

The areas where the provider must make improvement are:

  • Ensure that care and treatment of patients is only provided with the consent of the relevant person.
  • 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 improvement are:

  • Continue to improve the completion of e-learning and training deemed mandatory by the practice and that this is recorded effectively.
  • Complete annual appraisals for all staff.
  • Continue with plans to improve the identification of carers and provision of information to support carers.
  • Encourage the uptake of annual health checks for patients with a learning disability.
  • Check that learning identified from significant events and complaints had been actioned, and an annual analysis of trends for significant events is undertaken.

I am placing this service in special measures and while recognising that the Practice is on an improvement trajectory there needs to be clear vision and leadership cohesion for the Practice to continue to drive through the required improvements. 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 FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 08 September 2015

During an inspection to make sure that the improvements required had been made

Inspection carried out on 22 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Drs Seehra, Lockyer, Davis and Tanoe on 22 October 2014. The inspection team was led by a CQC inspector and included a GP specialist advisor and a practice manage specialist advisor.

Overall the practice is rated as requires improvement. Specifically, we found the practice to require improvement for providing safe and well led services. It was good for providing a caring, effective and responsive service. The concerns which led to these ratings apply to everyone using the practice.

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

• Drs Seehra, Lockyer, Davis and Tanoe are a caring practice with doctors who provide a high level of personal care to a large patient population. Each patient has a named doctor. The staff are very committed to acting in the best interests of the patients.

• Patients were satisfied with the service. They felt they were treated with dignity, care and respect and were involved in decisions about their care and treatment.

• The needs of the practice population were understood and services were offered to meet the needs of each patient group. The practice was proactive in helping mothers and babies in need of support. The practice ensured that patients in vulnerable circumstances could access relevant healthcare. Arrangements were in place to make sure that patients’ health was regularly monitored.

The areas where the provider must make improvements are:

• Ensure that all incidents and significant events are reported in line with the National Patient Safety Agency’s (NPSA) Reporting and Learning System (RLS) and improve their approach to monitoring significant events and incidents.

• Take reasonable steps to ensure that service users are safeguarded against the risks of abuse by ensuring their records identify the risks to children that the practice have been informed of.

• Implement an effective operation of systems to regularly assess and monitor the quality of the services provided.

In addition the practice should:

• Make information available to patients attending the surgery about their right to a chaperone service.

• Ensure that training records include all the training planned for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice