Horsmans Place Partnership Also known as Horsmans Place Surgery

We carried out an announced inspection at Horsmans Place Partnership on 17 May 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive – Requires improvement

Well-led – Inadequate

Following our previous inspection on 28 September 2016, 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 Horsmans Place Partnership on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to review the following domains:

• Safe
• Effective
• Caring
• Responsive
• Well-led

How we carried out the inspection/review

Throughout the 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
• A short 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 have rated this practice as Inadequate overall

We found that:

• Safeguarding policies had not recently been reviewed and updated.
• Disclosure and Barring Service (DBS) checks had not always been seen by the practice.
• Recruitment checks were not always carried out in accordance with regulations and practice policy.
• Staff vaccination was not always maintained in line with current Public Health England guidance.
• Risks to patients, staff and visitors were not always assessed, monitored or managed effectively.
• There was no record that reception staff had received training in the identification of ‘red flag’ signs or symptoms or sepsis in patients.
• The arrangements for managing medicines did not always keep patients safe.
• There was no formal clinical supervision or audit of the prescribing/consultations of non-medical prescribers
• Learning from significant events and complaints was not always shared with relevant staff.
• Systems for managing safety alerts were not always effective.
• Patients’ needs were assessed, but care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• Patients with long-term conditions were not always receiving relevant reviews that included all elements necessary in line with current best practice guidance and not all patient reviews were followed up where necessary in a timely manner.
• The practice carried out quality improvement activity, but there was not always evidence that they had implemented and followed up on the recommended changes.
• Staff worked together and with other organisations to deliver care and treatment which was not always effective.
• Staff treated patients and colleagues with kindness, respect and compassion.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected patients’ privacy and dignity.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• There was compassionate leadership at all levels. However, leaders were not aware of all required improvements to quality, safety and performance.
• Improvements were required to the processes and systems that supported good governance and management.
• The practice’s processes for managing risks, issues and performance were not always effective.
• Processes to manage current and future performance were not sufficiently effective.
• The policies and protocols for managing medicines did not always keep patients safe.

We found breaches of regulations. The provider must:

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

We took enforcement action and issued warning notices against the provider in relation to Regulation 12(1)(2) Safe care and treatment and Regulation 17(1)(2) Good governance.

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

The provider should:

• Ensure that household members of ‘at risk’ children are recorded as alerts on the clinical system.
• Ensure that a health and safety notice is displayed in the building and consider testing fire alarms more frequently.
• Ensure that Infection Prevention and Control (IPC) training is appropriate to the staff member’s role.
• Ensure that specimens are stored in an appropriate refrigerator overnight.
• Continue to investigate ways to improve uptake of childhood immunisations, cervical cancer screening and breast cancer screening.
• Engage in regular feedback and monitoring exercises with patients and staff.
• Consider redistribution of staff to increase those answering phones at busy times.
• Include the date and names of attendees when recording minutes.
• Consider ways to identify more carers and young carers.
• Encourage reforming the Patient Participation Group and appoint a Freedom to Speak Up Guardian.

I am placing this service into 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 Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care