We carried out an unannounced inspection at Patford House Surgery Partnership on 5 May and 10 May 2021 and conducted remote searches on the practice’s clinical system on 6 and 7 May 2021. Overall, the practice is rated as Inadequate.
Set out the ratings for each key question
Safe - Requires Improvement
Effective – Requires Improvement
Caring – Requires Improvement
Responsive - Inadequate
Well-led - Inadequate
Following our previous focused inspection in December 2020 we served warning notices on the provider for breaches of Regulation 17 Good governance of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the quality of care they are responsible for fell below expected standards and legal requirements. This previous inspection was unrated.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Patford House Surgery Partnership on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection to confirm that the practice had met the legal requirements in relation to the warning notices served after our previous inspection in December 2020 and to follow up on areas of concern identified to CQC.
How we carried out the inspection
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:
- Completing clinical searches on the practice’s patient records system
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
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 and Inadequate for all population groups.
At this inspection we found that not enough improvements had been made to address the breaches identified in the warning notice issued for Regulation 17 Good governance. We served further warning notice to the provider for breaches of Regulation 17 Good governance and Regulation 16 Receiving and acting on complaints.
We found that:
- Processes to identify and mitigate risk relating to fire, Legionella and Covid-19 were not effective.
- The practice could not be assured that all medical equipment was safe and appropriate for use.
- Processes introduced to manage practice tasks were not adequate.
- The monitoring of patients prescribed high risk medicines and those affected by medicines alerts, did not ensure patient safety.
- The processes to ensure significant events were raised, investigated appropriately and that learning was identified and shared in a timely way with relevant staff, were not always effective.
- The practice described how the pandemic had impacted on the processing of significant events as they prioritised other patient needs during this unprecedented time.
- Staff had access to training and development. However, the processes to ensure staff remained qualified and competent for their role required improvement.
- Since the inspection the provider has submitted evidence of up to date registration checks for all clinical staff.
- The practice could not provide assurances that all patients received effective care and treatment.
- The practice collated patient feedback from a variety of sources, However, improvements relating to concerns raised by patients were limited.
- Patient access was not monitored effectively to ensure services remained accessible to all patients as required.
- The practice’s complaints process was not adequate.
- Overall governance arrangements were ineffective.
- Improvements in practice culture had not been consistent to ensure all staff felt comfortable to raise concerns.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
- Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
The areas where the provider should make improvements are:
- Review oversight of monitoring of staff vaccinations to ensure practice policy is in line with national recommendations.
- Identify and implement actions to address areas of concern following patient feedback.
- Review arrangements for issuing staff rotas.
- Clinicians revalidation and appraisals should be reinstated within the timescales set out by NHS England in March 2020.
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 tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care