Archived: Overseal Surgery

We carried out an announced comprehensive inspection at Overseal Surgery on 17 September 2019 as part of our inspection programme. A comprehensive inspection was completed due to the practice changing registration to become a partnership. All key questions were inspected as part of 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 have rated this practice as inadequate overall.

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

• There were insufficient systems for safeguarding children and adults. Staff did not recognise or respond appropriately to abuse.
• The practice did not have clear systems and processes to keep patients safe.
• Safety alerts were not always acted on appropriately.
• Patients were not always receiving appropriate and safe treatment in line with national guidance.
• There was a lack of clinical oversight in the dispensary.
• The practice did not learn and make improvements when things did not go well.

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

• People’s care and treatment did not reflect current evidence-based guidance, standards and practice.
• There was limited monitoring of patients care or treatment including limited clinical audit which did not show any quality improvement.
• Clinical staff could not demonstrate they had the knowledge and skills to enable them to deliver quality care.
• There was not always documented consent to care and treatment, and mental capacity or Gillick competencies were not routinely recorded.

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

• The practice did not have clear and effective processes for managing risks, issues and performance.
• Leaders could not show they had the skills to deliver high quality, sustainable care.
• There was a lack of clinical governance within the practice.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

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

We rated the practice as Requires Improvement for providing caring services because:

• The practice was not proactive in identifying carers within the practice.
• There was a lack of confidentiality within the reception area where patient identifiable data and medical history easily heard.

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

• Patient with urgent concerns were not dealt with in a timely manner
• The practice was not easily accessible by patients in a wheelchair
• Complaints were not always recorded appropriately

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure patients are protected from abuse and improper treatment.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

• Continue to improve the identification and support of carers within the practice.
• Improve patient confidentiality in the reception area.

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