The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Firs

Overall: Inadequate read more about inspection ratings

26 Stephenson Road, Walthamstow, London, E17 7JT (020) 8223 9842

Provided and run by:
The Firs

All Inspections

6 and 7 June 2022

During a routine inspection

We carried out an announced comprehensive inspection of The Firs on 6 & 7 June 2022.

At our previous inspection on 27 October 2021, the practice was rated as inadequate overall (inadequate for ‘Safe’ ‘effective’ and ‘Well-led’, requires improvement for ‘responsive’ and good for caring).

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

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to look at the improvements made. At the inspection we inspected all key questions and the breaches of regulation found at the previous inspection.

How we carried out the inspection

We carried out a site visit over two days, where we carried out searches of and reviewed the clinical records, spoke with staff and reviewed documents.

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 have rated this practice as Inadequate overall

The ratings for the key questions are:-

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive – Requires Improvement

Well-led - Inadequate

At this inspection we have continued to rate the practice inadequate for providing a safe service because:

  • The provider failed to put an effective process in place for the structured annual medicines reviews for patients on repeat medicines. This puts patients at potential risk of harm.
  • The practice was unable to complete the backlog of work due to insufficient staff numbers.
  • The recall system for patients referred to secondary care did not check that patients with abnormal cervical screening results had attended their appointments.

At this inspection we have continued to rate the practice inadequate for providing an effective service, because we found patients were put at risk of harm. For example:

  • There were examples where current evidence-based guidance was not followed.
  • The practice had only carried out approximately 50% of the outstanding long-term health condition annual reviews.
  • The practice did not have a system in place to respond to the needs of patients who were receiving end of life care.
  • The practice had not assured that staff were competent for their roles.
  • Patient consultation records of long-term health conditions carried out by staff members were sometimes ineffective and had evidence that the patients care, and treatment was not appropriately reviewed.
  • The practices uptake for childhood immunisations and cervical screening was below the World Health Organisation targets.
  • The practice did not keep a copy of the patients Do Not Attempt Cardiopulmonary Resuscitation form on the patient records.

At this inspection we have continued to rate the practice as inadequate for providing well-led services. This is because we have continued to find: -

  • A number of concerns around lack of oversight of processes and ineffective clinical systems.
  • Some leaders could not demonstrate they had the capacity and skills to deliver high quality sustainable care.
  • We found gaps in the governance arrangements.
  • The practice continued to not have effective processes for managing risks, issues and performance.

At this inspection we have continued to rate the practice as requires improvement for providing a responsive service. This is because.

  • The practice only offered practice nurse appointments within working and school hours and this limited access to appointments for children and working adults.
  • The results from the practice’s own survey continued to demonstrate that patients found accessing appointments a poor experience.

At this inspection we rated caring as good because:

  • Feedback was generally positive about the way staff treated people.
  • The practice respected patients’ privacy and dignity.

We found two 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.

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

At our previous rated inspections in May and October 2021, the service was placed and remained in special measures. As a result of our findings at this inspection, the service will remain in special measures..

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27 October 2021

During a routine inspection

We carried out an announced comprehensive inspection of The Firs on 27 October 2021.

Following our previous inspection on 5 May 2021, the practice was rated as inadequate overall (inadequate for ‘Safe’ and ‘Well-led’, requires improvement for ‘Effective’, and ‘Caring’ and ‘Responsive’ were not inspected so the previous ratings of good were carried over).

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

Throughout the COVID-19 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 reduced amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements. This included:

  • Conducting staff interviews using video conferencing;
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider;
  • Reviewing patient records to identify issues and clarify actions taken by the provider;
  • Requesting evidence from the provider by email; and
  • A site visit to the practice.

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.

At this inspection, we have rated the practice as inadequate overall.

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

  • There was inconsistent follow-up from external safeguarding meetings.
  • There were delays in actioning test results and workflow tasks and a lack of oversight of these processes.
  • The system to monitor cervical screening results was not effective.
  • We identified instances where medicines for patients with specific long-term conditions had been issued without the appropriate monitoring having taken place.
  • The practice did not have an effective recall system in place to ensure that patients had regular structured medication reviews.

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

  • Patients’ needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance.
  • There was ineffective diagnosis, management and oversight of patients with long-term and other health conditions.
  • There was no system in place to ensure that patients had regular long-term conditions reviews or medication reviews to check their health and medicines needs were being met.
  • The practice’s childhood immunisation uptake rates for April 2019 to March 2020 were below the WHO targets for children aged two and five and there was not an effective recall system in place for childhood immunisations.
  • The practice’s uptake for cervical screening was below the Public Health England coverage target for the national screening programme and there was not an effective recall system in place for cervical screening.
  • Not all clinicians had the appropriate skills and training to carry out long-term condition reviews and checks.
  • There was no system to appropriately code, monitor and review Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.
  • Audit results were not consistently shared with clinical staff.

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

  • We identified a number of concerns relating to lack of oversight of processes and ineffective clinical systems.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • The practice did not have effective processes for managing risks, issues and performance. We identified several risks to patient safety which had not been recognised by leaders or management.
  • There were gaps in the overall governance arrangements.
  • The practice did not use data and information effectively to monitor and improve performance.

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

  • Feedback from patients indicated that they were not always able to access care and treatment in a timely way.
  • The practice’s GP patient survey results for 2021 were significantly below the national average in relation to telephone access.
  • Whilst the practice had made changes to its telephone system to improve access, it was too early to ascertain the impact of these changes and whether access had indeed improved for patients.

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

  • Staff treated patients with kindness, respect and compassion.
  • Feedback was generally positive about the way staff treated people.
  • The practice respected patients’ privacy and dignity.

The areas where the provider must make improvements are:

  • 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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review the system for identifying carers to ensure they are provided with the support they need.
  • Review the structure of internal practice meeting minutes to ensure that any agreed actions are monitored and followed up effectively.
  • Review the need for a system to monitor the work of the pharmacists.
  • Review the system for ensuring that audit results are shared with all relevant staff and that this is documented.

On 5 November 2021, The Firs was issued with an urgent notice to impose conditions upon their registration as a service provider in respect of regulated activities, under Section 31 of the Health and Social Care Act 2008. This notice of decision of urgent conditions was given because we believed that patients would or may have been exposed to the risk of harm if we did not take this action.

At our previous rated inspection in May 2021, the service was placed in special measures. As a result of our findings at this inspection, the service will remain 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. 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 table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14 July 2021

During an inspection looking at part of the service

We previously carried out an announced inspection of The Firs on 5 May 2021. At that inspection, we found the practice was in breach of Regulation 17: ‘Good governance’ of the Health and Social Care Act 2008. In line with the CQC’s enforcement processes, we issued a warning notice which required The Firs to comply with the regulations by 1 July 2021.

The Firs is currently rated as inadequate overall (inadequate for the key questions of ‘Safe’ and ‘Well-led’, requires improvement for ‘Effective’, and good for ‘Caring’ and ‘Responsive’).

The full report of the practice’s previous inspection can be found by selecting the ‘all reports’ link for The Firs on our website at www.cqc.org.uk.

We carried out this announced focused inspection on 14 July 2021 to check whether the provider had addressed the issues in the warning notice and now met the legal requirements. This report covers our findings in relation to those specific areas, is not rated, and does not change the current ratings held by the practice.

Throughout the COVID-19 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 did not require a site visit, and included:

  • Conducting staff interviews using video conferencing;
  • Requesting evidence be provided electronically in advance of the inspection;
  • Reviewing documents and information on the practice’s computer system and clinical system using video conferencing.

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.

At the inspection on 14 July 2021 we found the provider had taken action to address the issues we identified at the previous inspection, although there was one area in relation to staff training which was still in breach of the regulations.

Our key findings were as follows:

  • There were ineffective systems for staff training, in relation to mandatory training requirements for staff and monitoring completion of staff training.
  • The practice had systems in place to safeguard vulnerable patients at risk of abuse.
  • The practice had made improvements to its recruitment processes and ongoing employment checks.
  • Required actions relating to premises and equipment safety had been completed and documented appropriately.
  • The practice had implemented an effective system of clinical oversight for the nursing and healthcare staff.

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.

(Please see the specific details on action required at the end of this report).

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

05 May 2021

During an inspection looking at part of the service

We carried out an announced inspection of The Firs on 5 May 2021, looking at the three key questions of ‘Safe’, ‘Effective’ and ‘Well-led’

Following our previous inspection on 9 October 2019, the practice was rated as requires improvement overall (requires improvement for ‘Safe’, ‘Effective’ and ‘Well-led’, and good for ‘Caring’ and ‘Responsive’).

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

Throughout the COVID-19 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 with consent from the provider and in line with all data protection and information governance requirements. This included:

  • Conducting staff interviews using video conferencing;
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider;
  • Reviewing patient records to identify issues and clarify actions taken by the provider;
  • Requesting evidence from the provider; and
  • A short site visit to the practice.

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.

At this inspection, we have rated the practice as inadequate overall.

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

  • There were ineffective systems to safeguard vulnerable patients at risk of abuse.
  • We identified a range of issues with recruitment processes and ongoing employment checks. For example, in relation to Disclosure and Barring Service checks, professional registration checks, and records of staff immunity.
  • The practice had not carried out required actions relating to premises and equipment safety.
  • We found gaps in staff training in safeguarding, fire safety, basic life support and infection control.

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

  • The practice’s childhood immunisation uptake rates were below the World Health Organisation (WHO) targets and they had not taken any steps beyond the normal recall system to improve uptake rates. This had been identified as an area for improvement at our previous inspection in 2019.
  • The practice’s uptake for cervical screening was below the Public Health England coverage target and they had not taken any steps to improve this other than booking patients at local hubs through the local GP federation. This had been identified as an area for improvement at our previous inspection in 2019.
  • The practice could not demonstrate how they assured the competence of clinicians, including non-medical prescribers, as there were no systems for clinical oversight.
  • However, our review of patient records on the practice’s clinical system demonstrated that care and treatment was delivered in line with current standards and evidence-based guidance.

These areas affected all population groups, so we rated all population groups as requires improvement for providing effective services.

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

  • The delivery of high-quality care was not assured by the leadership or governance.
  • Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care. Many of the issues identified at this inspection had been raised as an issue at the previous CQC inspection in October 2019, however leaders had not acted in the interim to resolve these concerns.
  • The practice did not have clear systems to support good governance and management, for example in relation to systems for safeguarding patients, oversight of clinicians, recruitment and employment checks, monitoring staff training, and ensuring premises safety.
  • The practice did not have effective processes for managing risks, issues and performance.

The areas where the provider should make improvements are:

  • Ensure that information about requesting a chaperone is visible to patients in the reception and waiting area.
  • Clarify the responsibilities of the infection control lead.
  • Ensure referrals are monitored consistently and patient interactions recorded.
  • Take action to improve the uptake rate for childhood immunisations and cervical screening.

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.

(Please see the specific details on action required at the end of this report).

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 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 table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

9 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Firs on 9 October 2019 as part of our inspection programme.

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 and requires improvement for all population groups.

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

  • Learning from significant events were not adequately shared with relevant staff members.
  • There were flaws in the medicine management processes including prescribing and emergency processes.
  • Insufficient attention was paid to mitigating risks.
  • Staff training was not sufficiently monitored.
  • Care plans were not comprehensively written.

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

  • Learning from quality improvement was not adequately shared with relevant staff members.
  • There was insufficient oversight of QOF high exception reporting rates.
  • The practice did not achieve the childhood immunisation and cervical screening targets.

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

  • There was a lack of oversight in training and governance.
  • There was insufficient monitoring and management of risks.
  • There was disjointed working between staff members.
  • Systems and processes did not promote the sharing of learning from significant events and complaints.

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

  • Completed CQC patient comment cards and patients we spoke with all indicated the practice had a caring nature and were attentive to the needs of patients.
  • There was year on year improvement with patient satisfaction and the practice could demonstrate the actions they had taken to achieve this.

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

  • Patients had access to appointments outside of normal working hours.
  • There was a year on year improvement on patient satisfaction with access to services and the practice could demonstrate what they had done to achieve this.

The practice must:

  • Ensure care and treatment is carried out in a safe way.

The practice should:

  • Review the system for sharing learning.
  • Review personnel systems including DBS requirements
  • Continue to work to improve patient satisfaction with services.
  • Review the system for documenting, managing and mitigating risks.
  • Review the system for highlighting vulnerable patients.
  • Continue to work to improve childhood immunisation and cervical cytology uptake.
  • Review and update the palliative care register.
  • Review the system for identifying carers to ensure that they are provided with the support that they need.

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

15 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Firs on 15 June 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • 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 easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it difficult on occasions to get through on the phone and to make an appointment. However, urgent appointments were always available on 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 and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Ensure all non- clinical staff receive adult safeguarding training.
  • Ensure regular infection control audits are carried out.
  • Ensure regular fire drills are carried out.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Ensure all patients with Learning Disabilities receive annual reviews.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 November 2013

During a routine inspection

Most people had been attending the surgery for over 10 years and were very positive about all the staff at the practice. One person said "I love my doctor, I've recommended friends to come here."

People's privacy was maintained as people told us that staff did not walk in during consultations and the doctors told us that unless it was an emergency they did not want to be disturbed while seeing patients.

People were given time to speak to the doctor and to the nurse and people advised they did not feel rushed and the doctor answered all their questions.

Staff could tell us how to safeguard people at the surgery as they had a clear safeguarding policy for adults and children and could tell us how they would respond. Furthermore people at the practice told us they felt safe while seeing the doctor and never feel uncomfortable.

The surgery had procedures to maintain the cleanliness of the surgery and ensured staff had infection control training.

People told us they never had any reason to complain but would approach the reception staff or practice manager if they had concerns. The practice responded to complaints and followed their procedure to ensure they were investigated to people's satisfaction.