All inspections: Severn Surgery - Care Quality Commission

We carried out an announced focused inspection at Severn Surgery on 9 October 2023 to follow up on a Section 29 warning notice we issued at the previous inspection in June 2023 in relation to a breach of Regulation 12 Safe Care and Treatment.

In June 2023, the practice was rated as inadequate overall and also for the key questions of safe and effective. The practice was placed into special measures. This inspection took place on the 9 October 2023 to review compliance with the warning notices which needed to be met by 31 August 2023, but the inspection was not rated. The ratings from June 2023 therefore still apply and will be reviewed via a further inspection to take place within the next six months.

The ratings from June 2023 still apply and the service remains rated as inadequate overall and with the key question rated as follows:

Safe - inadequate

Effective - inadequate

Caring - good

Responsive - good

Well-led - requires improvement

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

Why we carried out this inspection

We undertook a focused inspection on 9 October 2023 to check that the practice had addressed the issues in the warning notice and now met the legal requirements. This report only covers our findings in relation to those requirements and will not change the ratings.

At the inspection, we found that all the requirements of the warning notice had been met.

How we carried out the inspection

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.

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 found that:

The service was compliant with the warning notices which had been issued at our previous inspection in June 2023.
Patients taking medicines which required monitoring had received required tests and were receiving safe care and treatment.
The practice had put in place processes to ensure patients with long term conditions were receiving effective care and their conditions were reviewed regularly.
The practice had implemented systems to receive and act on safety alerts in a timely manner. They had reviewed historical alerts to ensures patients were kept safe.
Patients test results were being acted upon and followed up appropriately to diagnose conditions where appropriate.

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 Health Care

We carried out an announced comprehensive inspection at Severn Surgery on 12 May 2023 to review their progress since taking over the contract at the practice. Overall, the practice is rated as inadequate.

Safe - Inadequate

Effective - Inadequate.

Caring - Good

Responsive - Good

Well-led - Requires improvement.

Following our previous inspection on 22 June 2022, the practice was rated as inadequate overall. The partnership of the practice changed in September 2022 and under our continuing regulatory history policy, the rating of inadequate was inherited. At this inspection, which is the first inspection of the new partnership, we found some improvements had been made to address areas of concern which were found at the previous inspection under the previous partnership, however some areas needed to continue to be embedded in order to improve.

The full reports for previous inspections can be found on our website at www.cqc.org.uk.

Why we carried out this inspection.

We carried out this inspection to follow up on previous concerns and the practice being in special measures. We reviewed all key questions as part of the inspection.

How we carried out the inspection.

Undertaking a site visit.
Conducting staff interviews remotely and on site.
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 to be submitted prior to the inspection and reviewing evidence during the 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 found that:

The practice did not always provide care in a way that kept patients safe and protected from harm.
Patients taking regular medicines were not always monitored in line with national guidance.
Safety alerts were not always being received and acted upon, which put patients at risk.
The practice did not always identify patients with long term conditions.
Not all patients received effective care and treatment that met their needs. Patients with long term conditions were not always being reviewed effectively.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Patients could access care and treatment in a timely way. On the day appointments were regularly available.
A new management and leadership structure had been implemented to support staff through the transition of services.
Systems and processes needed to be strengthened to support good governance in accordance with the fundamental standards of care.

We found two breaches of regulations. The provider must:

Ensure care and treatment are provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, there were areas the provider could improve and should:

Ensure Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) documentation is complete and full assessments have been documented.
Continue to complete reviews for patients with learning disabilities.
Continue to increase uptake rates for childhood immunisations and cancer screening.

This practice was placed in special measures following our previous inspection on 22 June 2022 when different partners were at the practice. The practice will be kept under review and a comprehensive inspection will be carried out at the end of the special measures period. If necessary we shall 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 the registration or to varying the terms of the registration if the practice does not improve.

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

We carried out an announced remote review at Spectrum Health on 13 July 2022 and onsite inspection on 18 August 2022. No rating was given.

Following our previous inspection on 6 and 22 June 2022, the practice was rated Inadequate overall and for the key questions safe, effective and well led, but good for providing caring and responsive services.

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

Why we carried out this inspection

This inspection was to follow up on:

Actions taken following a Notice of Decision to impose conditions that was issued following the previous inspection to the provider and registered manager.

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 reviews differently.

This review was carried out both remotely and 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 and discussing findings with the provider
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 not rated the practice at this review.

We found that:

Following a significant event, the deletion letters from secondary care for individual patients, the practice provided an audit they had completed to identify the patient letters that had been deleted from their records. During our remote review of the clinical system we found 27 out of 100 records we viewed had dates of letters from secondary care which didn’t align with the information provided on the audit.
A second audit found a number of administrative errors had impacted the ability to gain assurance that letters were in place.
A significant event investigation had taken place; however, this had not identified all areas for learning.

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

Sean O Kelly
Chief Inspector of Primary Medical Services and Integrated Care

We carried out an unannounced inspection at Spectrum Health on 6 June 2022. A further announced inspection was carried out on 22 June 2022. Overall, the practice is rated as Inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive - Good

Well-led - Inadequate

Following our previous inspection on 25 August 2021, the practice was rated Requires Improvement overall and for all key questions except effective which was rated as good and caring which was rated as outstanding.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on breaches of regulations identified at the previous inspection and to gain assurances following concerns raised with CQC about patient safety at the practice.

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 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:

The practice was unable to demonstrate effective processes were in place for the management of patient data. This included a plan to retrieve hundreds of patient letters that had been deleted.
The practice did not have clear systems and processes to keep patients safe. We found actions from medicine reviews were not acted on.
The practice did not have appropriate systems in place for the safe management of medicines. This included a lack of medicine reviews.
We found that on occasions clinical staff were left alone in the practice without access to a prescribing clinician.
Staff had been allocated roles but had not received the appropriate training to be able to do their roles effectively.
Governance processes were ineffective. We found limited oversight by the leadership team of outstanding tasks awaiting action.
A range of audits had been completed, however we found limited evidence of quality improvements.
Staff feedback showed they were unable to speak openly without the fear of retribution.
The practice had increased their opening hours and appointment availability following patient feedback.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found breaches of regulations. The provider must:

Ensure that care and treatment is provided in a safe way.
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.
Ensure the most recent CQC rating is clearly displayed.

In addition, the provider should:

Continue to improve the uptake of national screening programmes such as cervical screening.

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

We carried out an announced inspection at Spectrum Health between 24-25 August 2021. Overall, the practice is rated as requires improvement.

The ratings for each key question were:

Safe - Requires improvement

Effective - Good

Caring - Outstanding

Responsive – Requires improvement

Well-led – Good

Following our previous inspection on 27 November 2019, the practice was rated good overall and for four of the key questions, but requires improvement for providing responsive services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection including a site visit to follow up on:

The previous requires improvement for the responsive key question
A review of areas identified as ‘shoulds’ at the previous inspection
Performance indicators identified as being below local and national averages, for example, Quality and Outcomes Framework achievement, cancer screening, and childhood immunisation rates.
Concerns received directly by the Care Quality Commission (CQC) including the management of complaints, and access to see a GP.

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:

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 to be submitted electronically 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 requires improvement overall and for all population groups. However, the practice has been awarded an outstanding rating for providing caring services.

We found that:

The practice was not always providing care in a way that kept patients safe and protected them from avoidable harm.
Patients mostly received effective care and treatment that met their needs. However, cervical screening rates fell below the national target by 12%.
Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice provided numerous examples of charitable work and ways they had supported their local community. This included sponsorship, charitable donations, working with schools, and engaging with their vulnerable patients throughout the pandemic. They were able to demonstrate how this had impacted positively on health outcomes for patients.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way. However, complaints were not always managed in accordance with national guidance.
The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We found two breaches of regulations. The provider must:

Ensure care and treatment is provided in a safe way to patients.
Ensure an effective and accessible system is in place for identifying, receiving, handling and responding to complaints from people using the service, or people acting on their behalf

In addition, the provider should:

Improve the uptake of cervical screening to achieve the national target of 80%.
Provide senior clinical input to all appraisals involving members of the clinical team.

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

We had previously carried out an announced comprehensive inspection at Severn Surgery on 12 June 2019, as part of our inspection programme where the practice was rated as good overall and requires improvement in responsive. The full comprehensive report of all previous inspections can be found by selecting the ‘all reports’ link for Severn Surgery on our website at

We decided to undertake an announced comprehensive follow up inspection of this service on 27 November 2019 due to information of concern received.

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 and

We have rated this practice as good overall. The practice was rated as requires improvement for providing responsive services and this affected all population groups which were also rated as requires improvement.

We rated the practice as good for providing safe, effective, caring and well-led services because:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Staff treated patients with kindness and respect and involved them in decisions about their care.
The practice demonstrated awareness of Quality Outcomes Framework (QOF) performance and was taking action to improve patient outcomes.
The uptake of national screening programmes such as cervical screening and the uptake of childhood immunisations was below local and national targets. The practice received support from external services and developed an action plan to improve uptake.
The provider promoted the delivery of good quality, person-centred care. A reconfiguration of the service had resulted in a number of improvements including the recruitment of additional clinical staff. Records viewed during the inspection and our discussions with staff showed the provider was working to consolidate the changes and enable ongoing improvements.

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

Patients experienced difficulties accessing appointments to see a GP and nurse. The 2019 national GP patient survey showed patient satisfaction had declined in questions relating to the responsiveness of services provided.
The practice had an active Patient Participation Group (PPG), however, engagement between the practice and PPG required further development.
The premises was not easily accessible for people with a disability or reduced mobility.

Whilst we found no breaches of regulations, the provider should:

Continue reviewing and improving the outcomes of patients’ clinical conditions and take action to revisit clinical audits to establish whether changes resulted in quality improvements.
Continue taking action to improve the uptake of childhood immunisations as well as national screening programmes such as cervical screening and review the accuracy of data collection.
Improve access to GP and nurse appointments as well as continue taking action to improve patient satisfaction in areas identified in the most recent national GP patient survey.
Take action to fully address long-standing environmental issues relating to compliance with infection control guidance and accessibility for patients with a disability or reduced mobility.
Take action to improve staff engagement so that staff feel supported and able to participate fully in any current and future developments.
Improve collaborative relationships with patient representatives as well as stakeholders to build a shared understanding of challenges within the practice and actively engage and involve them in decision-making to shape services and practice culture.

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

We carried out an announced comprehensive inspection at Severn Surgery on 12 June 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 good overall. The practice was rated as requires improvement for providing responsive services and this affected all population groups which were also rated as requires improvement.

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

Patients found it difficult to access appointments to see a GP and nurse.
The environment was not always conducive in providing a good experience for patients. We identified issues relating to access into and around the building for people with a disability or reduced mobility.

We rated the practice as good for providing safe, effective, caring and well-led services because:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The way the practice was led and managed promoted the delivery of good quality, person-centred care. A recent reconfiguration of the non-clinical staff team had created some unrest although the provider was trying to consolidate the changes and work with staff to enable ongoing improvements.

Whilst there was no breach of regulations, the areas where the provider should make improvements are:

The practice should continue to improve access to GP and nurse appointments.
The practice should continue with plans to develop the premises. Site improvements should incorporate measures to address long-standing environmental issues relating to infection control compliance, and ensure that the site is made more easily accessible for patients with a disability or reduced mobility.
Following the recent change management programme and staff restructure, the practice should focus on ensuring staff feel supported and able to participate fully in any future developments.

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

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Severn Surgery on 05 October 2016. Overall the practice is rated as good.

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

All staff members had received a DBS check and a new system was in place to ensure all staff members had a DBS check carried out every three years.
Approriate recruitment checks had been carried out for new staff members and a checklist had been devised to ensure appropriate checks were completed before staff commenced employment.
A new system had been implemented to ensure relevant staff renewed their professional registration on an annual basis, for instance with the Nursing and Midwifery Council or General Medical Council.
Safety data sheets and risk assessments were in place for all control of substances hazardous to health (COSHH) products.
A staff member had been trained to be the designated health and safety lead and a full fire and health and safety risk assessment had been carried out in August 2016 and an action plan was in place to address the areas identified as needing improvement.
A clinical governance framework had been developed which identified specific leads for topics such as audits, clinical quality, mitigating risk and complaints.
Meeting templates had been devised to ensure at the beginning of each meeting all actions agreed were discussed to ensure they had been completed or an update with regards to progress was provided.
A detailed business plan was also in place which included the objectives for the practice and underpinned the practice vision.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Severn Surgery on 15 February 2016. Overall the practice is rated as requires improvement.

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

There was a system in place for reporting and recording significant events and staff were aware how to report an incident.
Staff were knowledgeable about the actions they would take if they had any safeguarding concerns.
There were embedded systems in relation to obtaining, prescribing, recording, handling, storing and security of medicines.
Not all staff acting as a chaperone had been risk assessed to ensure they were able to carry out the role or received a Disclosure and Barring Service (DBS) check, if appropriate.
Not all appropriate recruitment checks have been carried out before staff members started employment, as well as the monitoring of ongoing professional registration status.
Risk assessments and data sheets were not available for all control of substances hazardous to health (COSHH) products.
The practice had templates set up on the patient record system which reflected best practice guidelines and support planning of patient care with specific long-term conditions.
Clinical audits were carried out and improvements made to the service provision as a result.
Staff had the skills, knowledge and experience to deliver effective care and treatment and there was evidence of appraisals and personal development plans for all staff.
Unplanned admissions or readmissions were reviewed on a daily basis and care plans were altered, as necessary.
Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.
Patients said they were treated with dignity and respect and they were involved in decisions about their care and treatment.
We saw staff were polite and professional, they treated patients with kindness and respect, and maintained patient confidentiality.
A GP partner attended locality meetings to assist with the review of the local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
Most patients told us they found it easy to make an appointment.
Patients said there was continuity of care and were aware urgent appointments were available the same day, if needed.
Information about how to complain was available in the patient waiting area. Learning from complaints had been identified and the practice manager was taking action around the main theme.
There was no documented overarching governance framework to support the delivery of a strategy and good quality care. However, GP partners were aware of the need to improve record keeping and systems which monitored and outlined the vision for the practice.
Practice specific policies were implemented and were available to all staff.
A programme of clinical and internal audit was in place which was used to monitor quality and to make improvements.
There was a leadership structure in place and staff felt supported by management.
There was an active patient participation group which met on a regular basis. The practice acted on feedback from the group and also feedback from patients and staff.
The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty.

The areas where the provider must make improvements are:

The practice must review it’s governance arrangements to ensure all systems and processed are in place to ensure risks are identified and managed, for example in relation to risk assessments and monitoring of professional registrations.
Ensure all appropriate recruitment checks carried out before staff members start employment.

In addition the provider should:

Ensure a strategy is in place to identify the practice vision to support good quality patient care.

Consider carrying out an access audit to ensure all reasonable adjustments are made for all patients to access the service.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Severn Surgery

All Inspections

9 Oct 2023

During an inspection looking at part of the service

12/05/2023

During a routine inspection

13 July 2022 & 18 August 2022

During an inspection looking at part of the service

6 June 2022 and 22 June 2022

During a routine inspection

25 August 2021

During a routine inspection

27 November 2019

During a routine inspection

12 June to 12 June

During an inspection looking at part of the service

05 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

15 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)