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Archived: Horsefair Surgery

Overall: Good read more about inspection ratings

Horse Fair Surgery, Banbury, Oxfordshire, OX16 9AD (01295) 259484

Provided and run by:
Horsefair Surgery

All Inspections

4 and 5 December 2018

During a routine inspection

This practice’s last comprehensive inspection was on 3 May 2018 and CQC issued a rating of requires improvement and took enforcement action.

A focussed follow up inspection took place on 5 July 2018. As a result of our findings in July 2018 we undertook enforcement action following the inspection.

We carried out an announced comprehensive inspection at Horsefair Surgery on 4 and 5 December 2018 as part of our inspection programme.

At this inspection we found improvements had been made:

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Good

At this inspection we found:

  • The practice had clear systems to manage risks to patients and staff. When incidents occurred, the practice learned from them and improved their processes.
  • The practice had implemented systems to monitor and improve effectiveness and appropriateness of care.
  • Clinical record keeping had been reviewed and improved.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients often found the appointment difficult to use and reported that they had long waits on the phone to book appointments. Monitoring of the phone system was underway to identify improvements.
  • The practice continuously reviewed the needs of its patient population and adapted processes to improve services for its population.

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

Additionally, the provider should:

  • Continue to improve long term condition care towards ensuring appropriate care is provided to those with chronic conditions.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

5 July 2018

During an inspection looking at part of the service

This practice was previously inspected on 3 May 2018 and CQC issued a rating of requires improvement. We rated each domain as follows:

Safe: Requires improvement

Effective: Requires improvement

Caring: Good

Responsive: Requires improvement

Well-led: Inadequate

We took enforcement action against the provider.

We carried out an announced focussed follow up inspection at Horsefair Surgery on 5 July 2018. We undertook this inspection to identify whether improvements had been made in regards to the warning notice we issued in May 2018.

At this inspection we found:

Some improvements had been made to specific areas highlighted at the previous inspection. However, we identified broader concerns of inaccurate recording and monitoring of patient care which posed risks to patients.

For example:

  • Coding used to identify what care patients had received and to monitor performance in national data submissions showed consistent inaccuracies in the areas of patient care we reviewed.
  • We found patients on mental health registers had not received care in line with national guidance.
  • Governance processes were not identifying the extent of risks to patients or omissions in care tasks.
  • The system for monitoring patients on high risk medicines ensured reviews of patients on these medicines took place in. However, we found examples where medicine reviews were undertaken by staff who were not qualified to do so and where action was completed following a blood test.

We also found positive outcomes regarding patient care.

  • We found examples of appropriate care and responses to vulnerable patients’ needs, including those on the child at risk register and patients with learning disabilities.

The areas where the provider must make improvements are:

  • Implement appropriate systems to assess, monitor and improve the quality and safety of the services provided and assess and mitigate risks related to the health, safety and welfare of patients.
  • Ensure that accurate records of patient care are maintained.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

3 May 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous inspection 05 December 2017 – rated Requires Improvement)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Horsefair Surgery on 3 May 2018. We undertook this inspection to identify whether improvements had been made since our previous inspection in December 2017 when the practice was rated requires improvement. Prior to the December 2017 inspection the practice had been in special measures and we had undertaken enforcement action.

At this inspection we found:

Some improvements had been made to the practice. However, we identified concerns in similar areas of the service where we had in previous inspections.

For example:

  • National data submissions showed improvements in the effectiveness and appropriateness of many care and treatment outcomes, but there was still lower than average performance in some areas including asthma.
  • There were still gaps in governance processes which had not enabled improvements in specific areas where we had identified previous risks. For example, the patient record system was not always accurate, which posed a risk to long term prescribing management and recording of patient data such as care plans.
  • The practice was well maintained, accessible and risks to the premises and health and safety were well managed.
  • Patients told us that staff were compassionate and caring.
  • Patient feedback indicated that there had been some improvement to the ability to book appointments but that there were still significant problems for some in accessing continuity and ongoing care via the appointment and telephone system.
  • Staff received training and development where needed. There was a system to monitor ongoing training.
  • Staff we spoke with reported a positive change to the service after a difficult period of time in recent years.
  • There was some focus on continuous learning and improvement within the practice.
  • Communication between patients and the patient participation group (PPG) had improved to enable reporting of concerns and responses to patients and the public to highlighted issues such as appointment access.

The areas where the provider must make improvements are:

  • Implement appropriate systems to assess, monitor and improve the quality and safety of the services provided and assess and mitigate risks related to the health, safety and welfare of patients.
  • Ensure that a secure and accurate record of patient care is maintained.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

5 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall.

At our previous comprehensive inspection in May 2017 the practice had an overall rating of Inadequate. We also undertook a responsive follow up inspection in August 2017 following which we issued warning notices.

Following the December 2017 inspection, the key questions are rated as:

  • Are services safe? – Good
  • Are services effective? – Requires improvement
  • Are services caring? – Good
  • Are services responsive? – Requires improvement
  • Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

  • Older People – Requires improvement
  • People with long-term conditions – Requires improvement
  • Families, children and young people – Requires improvement
  • Working age people (including those recently retired and students – Requires improvement
  • People whose circumstances may make them vulnerable – Requires improvement
  • People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Horsefair Surgery in Banbury, Oxfordshire on 5 December 2017. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Horsefair Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • Improvement plans were being implemented and were showing advances in the areas of concern identified at the previous inspections.
  • The practice had  defined systems, processes and practices to minimise risks to patient safety. The improvements to patient care were in progress but not yet completed.
  • There was a system in place to monitor whether staff had received training appropriate to their roles. Any further training needs had been identified and planned.
  • Our findings showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.
  • Clinical outcomes in national data submissions showed improved performance in some areas, particularly long term medicine reviews. However, the process for reviewing patients with long term conditions was not adequate as some patients had not received a review in over three years.
  • We received mixed feedback from patients. There was positive feedback regarding staff and care but also negative feedback regarding access to the phone lines and appointments, which had affected some patients care.
  • External stakeholders reported improvements to the service since August 2017.
  • The practice learned lessons from individual concerns and complaints and also from analysis of trends.
  • The practice had clinical and managerial leadership and supporting governance arrangements.

The areas where the provider must make improvements are:

  • Ensure risks to patients are identified, assessed and mitigated to protect patients’ health and welfare.

The areas where the provider should make improvements are:

  • Consider Hepatitis B vaccinations for reception staff in line with the practice policy on infection control.

This service was placed in special measures in June 2017. I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Horsefair Surgery on 9 May 2017. The overall rating for the practice was inadequate, specifically in providing effective and well led services, requires improvement for providing safe services and good for caring and responsive services. We issued warning notices in relation to breaches of the regulations in safe care and treatment and good governance. We placed the practice in special measures for six months. We previously inspected the practice in August 2016 where we found concerns leading to a rating of inadequate in effective and an overall rating of requires improvement. We issued requirement notices at that time. The full comprehensive report from the inspection can be found by selecting the ‘all reports’ link for Horsefair Surgery on our website at www.cqc.org.uk.

We undertook an unannounced focussed responsive inspection on 30 August 2017. This inspection was undertaken to determine whether improvements were made following the inspection in May 2016 and due to concerns raised with CQC regarding the safety of the service. Whilst improvements had been made in relation to the concerns highlighted at the last inspection, there were areas relating to staffing and governance which continued to place patients at significant risk. We have issued warning notices instructing the provider they must comply with regulations.

Our key findings were as follows:

  • There was evidence that issues identified during our last inspection were in the process of being addressed and plans were in place to improve some areas of governance.
  • However, there were still significant concerns regarding governance specifically the partners’ involvement in the leadership of the practice.
  • Staff told us that they believed clinical staffing levels were unsafe as tasks related to patient care, such as prescriptions and correspondence, were not always handled correctly due to the pressure caused by low staffing numbers.
  • Although we found most clinical tasks were up to date there were examples where there were omissions in patients care due to processes not being followed.
  • There was no clear system to assign patients requesting care or treatment to appropriate professionals. This meant that clinical staff may be treating patients without the skills and knowledge to safely do so. Patients informed us via comment cards and verbally that they found it difficult to book appointments and to get through on the practice’s phone system. Some told us the continuity of care provided was poor due to the lack of consistent GPs and the inability to book appointments.
  • A local care home reported concerns with the level of care received by their residents from the practice.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Review staffing levels and ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to ensure the safety and welfare of patients.
  • Ensure a system is in place to enable patients to be seen by a clinician with the appropriate skills and knowledge to meet their needs.
  • Improve governance systems to ensure the leadership team can assess, monitor and improve the quality and safety of the services, specifically in terms of clinical care.
  • Review governance systems to ensure they are tailored to the practice’s needs and that they enable the ongoing identification, assessment and monitoring of risks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Horsefair Surgery on 24 August 2016. The overall rating for the practice was requires improvement with one rating of inadequate for providing effective services, requires improvement for providing safe and well-led services and good for caring and responsive services. We issued requirement notices in relation to breaches of the regulations in safe care and treatment, good governance and staffing. The full comprehensive report from the inspection can be found by selecting the ‘all reports’ link for Horsefair Surgery on our website at www.cqc.org.uk.

We undertook a comprehensive follow up inspection on 9 May 2017. This inspection was undertaken to determine whether improvements were made following the inspection in August 2016. Whilst improvements had been made in relation to some of the concerns highlighted at the last inspection, there were areas relating to patient care and treatment and breaches of regulation which had not been addressed. . The practice is rated inadequate overall and specifically as inadequate for providing effective and well-led services, requires improvement for providing safe services, but good for providing caring and responsive services.

Our key findings were as follows:

  • Governance arrangements had not improved since our previous inspection and had not enabled the provider to make improvements to all of the areas where we found breaches of regulations.
  • Specifically, those relating to the care and treatment of patients with long term conditions had not been addressed by the practice. Effective action had not been taken to mitigate the risks highlighted and ensure improved patient outcomes.
  • National data submissions from 2016/17 showed a decline in performance around the care and treatment of patients with long term conditions.
  • Risks related to medicines were not always appropriately managed. Patients’ medicine reviews were still not being recorded or undertaken in line with national guidance to enable appropriate monitoring.
  • There was no system in place to monitor outcomes and drive improvements, including completed clinical audit cycles.
  • Staff were able to access clinical training in order to provide them with the skills, knowledge and experience to deliver effective care and treatment. However, training requirements were not monitored to ensure they were being undertaken by all staff.
  • There was a system in place for reporting and recording significant events. Reviews of complaints, incidents and other learning events were thorough.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patient feedback in CQC comment cards showed patients were satisfied with the approach of staff and they felt they received a quality service.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The provider was aware of and complied with the requirements of the duty of candour.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Assess, monitor and improve the quality and safety of the services provided in the delivery of care to patients.
  • Ensure medicine reviews are recorded in an accurate and timely manner to support patient care.
  • Review and improve long term conditions management to ensure improved patient health outcomes.
  • Improve the monitoring of clinical care to ensure areas where improvements are required are identified and acted on. For example, through completion of clinical audits.
  • Ensure all staff undertake the necessary training related to their roles and appropriate records are kept to monitor training.
  • Review policies to ensure they are practice specific and that staff can access the appropriate guidance.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take further 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 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.

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

24 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Horsefair Surgery on 24 August 2016. Overall the practice is rated as requires improvement. Although the caring and responsive domains are rated as good, improvements are required to ensure the service is providing safe and well-led services. The practice is rated inadequate for providing effective services.

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

  • There was a system in place for reporting and recording significant events. Reviews of complaints, incidents and other learning events were thorough.
  • Risks to patients were assessed and managed. However, some risks were not fully managed specifically in relation to monitoring of fridge temperatures, emergency medicines, medicine alerts and prioritisation of patients via the phone call-back system.
  • Staff assessed patients’ ongoing needs and delivered care in line with current evidence based guidance.
  • National data suggested most patients received appropriate care for long term conditions. However, there were many patients who were exempted from national data and therefore did not receive care in line with national guidance, which may support more positive health outcomes.
  • The practice had 6.5 whole time equivalent GPs and this was due to drop to five in October. This was partly caused by long term absence of two partners due to illness.
  • The system for reviewing patients on repeat medicines identified patients who required a review, but the practice was not always recording when these took place to ensure full monitoring of the system was happening.
  • Staff were trained in order 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patient feedback in CQC comment cards found some concerns regarding making an appointment since the introduction of the new phone consultation service. National survey results from July 2016 showed patients were able to booked appointments with GPs and nurses, but this did not reflect the recent changes.
  • 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.
  • There was a strong ethos of continuous learning and improvement.

Areas the provide must make improvements are:

  • Improve the monitoring of emergency medicines, equipment and medicine fridges.
  • Ensure any action related to medicine alerts is dealt with and reviewed appropriately by inclusion in systems of clinical governance.
  • Ensure the appropriate recording of medicine reviews takes place to ensure monitoring of this system can take place.
  • Review and improve the numbers of patients provided with long term condition reviews as reported in national data and where possible reduce those patients excluded from reviews that may reduce positive health outcomes.
  • Improve the monitoring of clinical care to ensure risks are identified, assessed, managed and mitigated wherever possible. For example, through completion of clinical audits.
  • Provide appropriate written guidance or prompts for reception staff to ensure they have access to information that will enable them to safely prioritise patients with an urgent need.

Areas the provide should make improvements are:

  • Continue to review, monitor and adjust the appointment system to ensure it meets patients’ needs.
  • Provide guidance and training to relevant staff in the Mental Capacity Act 2005.
  • Ensure that training provided to nurses in child safeguarding meets the requirements for level two.
  • Review the needs of patients with learning disabilities to ensure their care needs are met.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice