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The Surgery - Dr Mangwana and Partners Inadequate Also known as Palace Surgery

Reports


Inspection carried out on 9 December 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at The Surgery-Dr Mangwana and Partners on 09 December 2019.

The practice was previously inspected on 6 August 2019. Following this inspection, the practice was rated Inadequate overall and in safe, effective and well-led domains and placed in special measures. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). The practice was required to address these concerns by 4 October 2019.

We did not review the ratings awarded to this practice at this inspection.

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 the provider had made sufficient improvements in providing safe services regarding:

  • Safeguarding processes and DBS checks for clinical staff.
  • A fail-safe system to monitor and manage patient safety alerts.
  • Safety and security of its prescribing system.
  • Cold chain in relation to the safe refrigeration of vaccines.
  • Emergency medicines provision.
  • Staff recruitment checks.

We found the provider had not made sufficient improvements in providing safe services regarding:

  • A fail-safe system to monitor and manage patients who had been prescribed high-risk medicines.
  • A fail-safe system to monitor and manage patients who had been referred via the urgent two week-wait referral system.
  • A fail-safe system in place to safely manage and monitor cervical smear screening.
  • Infection prevention and control practices.
  • The oversight and operation of patient group directions (PGDs’).

We found the provider had made improvements for providing effective services regarding:

  • All staff had completed regular training regarding infection control, basic life support, fire safety and information governance.
  • Appraisals for the practice nurse and healthcare assistants.

We found the provider had not made improvements for providing effective services regarding:

  • Staff did not have the skills, knowledge and experience to deliver effective care, support and treatment. The provider did not undertake clinical supervision for the practice nurse and healthcare assistant.

We found the provider had made some improvements to concerns we found in the well led domain:

  • The instigation and oversight of an effective system to monitor and manage patient safety alerts.
  • The instigation and oversight of a safe effective system to monitor and manage emergency medicines.
  • The instigation and oversight of a safe effective system to monitor and manage recruitment.

However, they could not demonstrate they had:

  • Effective processes in place for managing risks, issues and performance.

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.

The service will remain in special measures until we have undertaken the next inspection and this will be reviewed at that time. This 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

Inspection carried out on 6 August to 6 August 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Surgery Dr Mangwana and Partners on 6 August 2019. This was a follow-up to our last inspection on 26 September 2018 when we rated the provider as requires improvement overall, and requires improvement in safe, effective and well led domains.

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 rated the practice as inadequate for providing safe services because:

•The practice did not have reliable systems and processes to keep patients safeguarded from abuse.

•The practice did not have safe systems regarding the management of patients on high-risk medicines.

•The practice did not have reliable infection prevention and control practices in place.

•The practice did not maintain adequate records to monitor and manage the cold chain effectively.

•The practice did not have complete fire safety systems in place.

•The practice did not have reliable systems in place to manage health and safety and the practice premises safely.

We rated the practice as inadequate for providing effective services because:

•The provider could not demonstrate people’s needs were assessed and care and treatment delivered, in line with current legislation, standards and evidence-based guidance.

•The provider could not demonstrate how people’s care and treatment outcomes were monitored and how they compared with other similar services.

•The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

•The provider could not demonstrate how staff and services work together to deliver effective care and treatment.

•The provider could not demonstrate they monitored consent to care and treatment.

•Some performance data was significantly below local and national averages.

•The provider could not demonstrate how they supported people to live healthier lives.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as good for providing caring services because:

•Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.

•Staff helped patients to be involved in decisions about care and treatment.

•The practice respected patients’ privacy and dignity.

•The practice had systems in place to identify carers and provide relevant support.

We rated the practice as good for providing responsive services because:

•Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.

•The practice had good facilities and was well equipped to treat patients and meet their needs.

•Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.

We rated the practice as inadequate for providing well-led services because:

•Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.

•The overall governance arrangements were ineffective.

•The practice did not have an appropriate fail-safe system in place for the safe management of patients who had been referred via the two-week wait urgent referral system.

•The practice did not have an appropriate fail-safe system in place to monitor and manage cervical screening for female patients.

•The practice did not have an appropriate fail-safe system in place to monitor and manage prescribing and prescriptions safety.

•The provider did not have a safe or effective recruitment system in place.

•The provider did not have a safe or effective system in place to monitor and manage emergency medicines and equipment.

•While the practice had a clear vision, that vision was not supported by a credible strategy.

•The practice did not have clear and effective processes for managing risks, issues and performance.

•The practice did not always act on appropriate and accurate information.

•We saw limited evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

•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.

The areas where the provider should make improvements are:

•Improve the identification of carers.

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

During a routine inspection

This practice is rated as requires improvement overall.

(Previous rating 18 July 2017 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at The Surgery - Dr Mangwana and Partners on 25 September 2018 as part of our inspection programme to follow up on breaches of regulations identified during an announced focused inspection carried out on 18 July 2017 to check whether the practice had carried out their plan to address the requirements.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed, with the exception of those relating to safeguarding and arrangements to deal with emergencies.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Consider ways to improve child immunisation uptake rates.
  • Ensure that actions from the recent fire risk assessment are completed and recommendations complied with.
  • Continue to monitor the National GP Patient Survey results and take steps to improve performance.
  • Continue to identify and support patients who are carers.

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

Inspection carried out on 18 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mangwana and Partners, The Surgery on 17 November 2015. The practice was rated as requires improvement for providing effective and responsive services and the overall rating for the practice was requires improvement. The full comprehensive report on the November 2015 inspection can be found by selecting the ‘all reports’ link for The Surgery – Dr Mangwana and Partners on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 18 July 2017 to check for improvements since our previous inspection. Overall the practice is now rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety. However, there was no effective system in place to monitor patients on high risk medicines.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and 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.
  • Patients we spoke with said they could make an appointment with a named GP in a reasonable timeframe and there was continuity of care, with urgent appointments available the same day.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs.
  • There was a leadership structure although not all staff were clear on who to report to with specific concerns. Staff felt supported by management however some staff said they would like more opportunities for career progression.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

  • Ensure the proper and safe management of higher risk medicines

In addition, the provider should:

  • Implement a register of vulnerable children to manage and review risk

  • Provide more support for staff to develop their roles within the practice

  • Continue to identify and support patients who are carers

  • Clarify the governance structure with clear lines of responsibility

  • Consider ways to improve child immunisation uptake rates

  • Develop a comprehensive program of quality improvement including clinical audit

  • Formalise the strategy to deliver the practice vision

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 17 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mangwana and Partners, The Surgery on 17 November 2015. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Risks to patients were assessed and well managed, with the exception of those relating to safeguarding and arrangements to deal with emergencies.

  • Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • There was no practice complaints policy in place procedure in line with recognised guidance and contractual obligations for GPs in England.

  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

  • 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.

The areas where the provider must make improvement are:

  • Ensure all staff receive safeguarding training and annual basic life support training relevant to their role.

  • Implement a programme of quality improvement to include clinical audit to improve patient outcomes.

  • Develop the practice complaints policy and procedure in line with recognised guidance and contractual obligations for GPs in England, maintain a log of all complaints received and analyse these in order to share lessons learned with staff.

The areas where the provider should make improvement are:

  • Ensure all staff who act as chaperones have been trained to provide this role and the service is advertised as available to patients.

  • Develop an inventory of all clinical equipment used within the practice.

  • Develop a comprehensive business continuity plan for major incidents such as power failure or building damage which includes emergency contact numbers for staff.

  • Ensure all policies are available to all staff and are practice-specific rather than generic.

  • Advertise the translation service within the practice to inform patients this support is available to them as required.

  • The practice should ensure systems are in place to proactively identify patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice