Southfield Way Surgery

We carried out an announced comprehensive inspection at Southfield Way Surgery on 12 December 2022. Remote clinical searches were undertaken on 9 December 2022. Overall, the practice is rated as requires improvement .

Safe - requires improvement

Effective – requires improvement

Caring - good

Responsive – requires improvement

Well-led - inadequate

Following our previous inspection on 16 December 2015, 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 Southfield Way Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection due to the length of time the practice was previously rated. We assessed all key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.
• Staff feedback questionnaires.

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 requires improvement overall.

We rated the practice as requires improvement for providing safe care and treatment. This was because:

• Staff recruitment checks had not always carried out in accordance with policy and regulations.
• Not all staff had completed training in safe working practices.
• There was little evidence of documented staff induction on the staff files we sampled.
• A comprehensive assessment to mitigate any potential risks of staff who declined to be immunised had not been carried out.
• The systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others were not effective.
• The practice did not always work in line with their significant event policy to allow reflection, learning and improve patient care.
• Clinical waste was not held securely prior to disposal.
• Medicine reviews were not structured or adequately documented to ensure that all monitoring requirements were checked as part of the review.
• Processes for the safe handling of requests for repeat medicines were not effective as not all patients had received the required monitoring.
• There were not sufficient numbers of suitably qualified and competent persons deployed to provide safe care and treatment.

We rated the practice as requires improvement for providing an effective service. This was because:

• Patients with long-term conditions had not always received the required monitoring to check their health and medicines needs were being met.
• The practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles safely and effectively or new staff had received an effective induction to support their learning.
• The practice did not have an effective system in place to monitor staff working in advanced roles.

We rated the practice as good for providing a caring service. This was because:

• Staff treated patients with kindness, respect and compassion.
• The practice had identified 94 of their patients as carers. This was 2.8% of the practice population.

We rated the practice as requires improvement for providing a responsive service. This was because:

• The practice had not always been responsive to the needs of its patients.
• People were not always able to access care and treatment in a timely way.
• Complaints were not always handled in line with the complaints policy or managed in a way to demonstrate learning and drive improvement.

We rated the practice as inadequate for providing a well-led service. This was because:

• Structures, processes and systems to support good governance and management were not effective.
• Leaders could not demonstrate that they had the capacity and skills to address the challenges within the practice.
• Policies to support the governance and safe running of the practice were not always adhered to.
• Processes for managing risks were not effective.
• Patient paper records and vaccines were not held securely.
• There was no overarching system in place to identify trends in complaints or significant events or to review the effectiveness of any possible changes made within the practice.

We found 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.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services