Archived: Elmdene Surgery

We carried out an unannounced comprehensive inspection at Elmdene Surgery and the branches at Bennett Way Surgery and Bean Surgery on 19 and 20 November 2019 due to concerns raised by patients and other stakeholders. This was the provider’s first inspection since registering with CQC as an individual in July 2019.

Previously the provider was in a registered partnership at Elmdene Surgery. The surgery was inspected was inspected in July 2018 and found to be inadequate overall and inadequate in safe, effective and well-led domains and all the population groups. It was rated requires improvement in the caring and responsive domains. The practice was placed in to special measures and issued with warning notices. In November 2018 CQC re-inspected Elmdene Surgery to ascertain if the requirements of the warning notice had been met, which they had. Following the inspection in November 2018 the partnership dissolved and the provider registered with CQC as a registered individual.

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 always have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Risks to patients were not appropriately assessed and any actions required to address or minimise risk, had not been completed.
• Staff did not always have the information they needed to deliver safe care and treatment.
• The practice did not have appropriate systems for the safe management of medicines including at the dispensaries.
• The practice did not have an effective system to learn and make improvements when things went wrong.

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

• Care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance.
• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Staff did not always work together and with other organisations to deliver effective care and treatment.

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

• The practice was unable to demonstrate how they made use of feedback from patients.
• National GP patient survey results were generally below Clinical Commissioning Group (CCG) and national averages.
• The practice did not always respect patients’ privacy and dignity.

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

• The practice did not always organise and deliver services to meet patients’ needs.
• People were not always able to access care and treatment in a timely way.
• National GP survey results with respect to telephone access, making an appointment and the type of appointments available were below Clinical Commissioning Group (CCG) and national averages.
• Complaints were not always used to improve the quality of care.

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

• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The practice had a vision, but it was not supported by a credible strategy, to provide high quality sustainable care.
• The practice culture did not always support sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks and identified issues.
• The practice did not always act on appropriate and accurate information.
• The practice did not always involve the public, staff and external partners to sustain high quality and sustainable care.
• There was little evidence of systems and processes for learning, continuous improvement and innovation.

We took urgent enforcement action and served an Urgent Suspension Notice on the service provider’s registration in respect of the regulated activities carried out at all registered locations Elmdene Surgery (including branch surgeries at Bean Surgery and Bennett Way Surgery) and Joydens Wood Medical Centre. The urgent suspension for all registered locations took effect on 26 November 2019. We took this action as we believe that a person will or may be exposed to the risk of harm if we did not do so.

As there are exceptional circumstances in this instance, CQC have considered that placing the practice into special measures would not be appropriate at this time.

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