The Care Quality Commission
  • Doctor
  • GP practice

Catherine House Surgery

Overall: Requires improvement read more about inspection ratings

New Walk, Totnes, TQ9 5WB

Provided and run by:
Catherine House Surgery

Important: This service was previously registered at a different address - see old profile

All Inspections

NA

During an inspection looking at part of the service

We carried out a deskbased review of Catherine House Surgery on 29 September 2022. The ratings have not changed because we did not visit the practice.

At our previous inspection on 13 April 2022 the practice was rated Requires Improvement overall:

Safe - Inadequate

Effective – Requires Improvement

Caring – Good

Responsive - Good

Well-led – Requires Improvement

We issued the provider with a requirement notice for a breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in regard to establishing effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also issued the provider with a warning notice for breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regard to safe care and treatment.

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

Why we carried out this inspection

We have continued to monitor the provider’s progress against their action plan which included regular meetings with them and also the commissioner. NHS Devon.

To gain further assurances we undertook a remote regulatory assessment on 29 September 2022 to establish whether the warning notice had been met.

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.

During this assessment, we reviewed Catherine House Surgery clinical records system which included the practices management system and sampled patient electronic records.This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Requesting evidence from the provider
  • Completing clinical searches on the practice’s clinical patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by 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 carried out the remote assessment
  • information from our ongoing monitoring of data about services and
  • information from the provider and commissioning body

Rmote searches fo the ractice’s clinical patient records system deomstratedWe found:

  • Clinical records were now detailed, evidencing appropriate engagement and agreed reduction plans were in place and monitored for patients who were on high risk medicines.
  • Systems were improved and searches and sampling of patient records of those with long-term conditions had appropriate recalls to be seen and in date reviews to ensure treatment continued to meet their needs.
  • The practice now had effective systems to review new patients’ medicines in a timely way after registering with the practice.
  • The practice now had effective systems for the appropriate and safe use of medicines, including medicines optimisation.

Details of our findings and the evidence supporting this are set out in the evidence table.

We continue to monitor the providers action plan in regard to the regulatory notice and will report on progress when we next inspect and rate the service.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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

13 April 2022

During an inspection looking at part of the service

We carried out an announced inspection at Catherine House Surgery on 13 April 2022. Overall, the practice is rated as Requires Improvement.

Safe - Inadequate

Effective – Requires Improvement

Well-led – Requires Improvement

Following our previous inspection on 31 March 2016 the practice was rated Good overall and Good for all key questions.

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

Why we carried out this inspection

This inspection was a focused inspection incorporating remote searches, interviews of staff and a site visit.

  • The ratings for Caring and Responsive were carried forward from the previous inspection. Both are rated Good.

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 from the provider
  • A short site visit
  • Conducting an interview with a Patient Participation Group member
  • A pre-site visit staff questionnaire
  • Obtaining written feedback from patients about the practice

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 have rated Safe as Inadequate, because we found:

  • Searches highlighted a number of patients potentially at risk due to a lack of monitoring or diagnosis.
  • We found no recorded reason and limited documentation in clinical records where polypharmacy presented significant risks to patients.
  • The practice was unable to evidence that all patients diagnosed with long-term conditions had received a review to ensure treatment continued to meet their needs. The practice did not have effective systems to review new patients’ medicines in a timely way after registering with the practice.
  • Systems in place to learn and make improvements when things went wrong were not fully embedded.
  • The practice did not have effective systems for the appropriate and safe use of medicines, including medicines optimization.
  • Infection and prevention control processes were not fully embedded.

However, we found areas where safety was effective:

  • There were clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • There were adequate systems to assess, monitor and manage risks to patient safety.
  • Staff had the information they needed to deliver safe care and treatment.

We rated Effective as Requires Improvement because we found:

  • Patient’s needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance.

However, we found areas of effective care and treatment:

  • The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles.
  • Staff were consistent and proactive in helping patients to live healthier lives.

We rated Well Led as Requires Improvement because we found:

  • Overall governance arrangements did not provide sufficient assurance of ongoing resilience and evidence of effective management of risks as an expanding practice.
  • Processes for managing risks, issues and performance were not fully embedded. They did not provide assurance that all risks were mitigated as far as reasonably practicable.

However, we found areas of positive leadership, culture and improvement:

  • There was compassionate, inclusive and effective leadership at all levels.
  • The practice had systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.
  • There was a demonstrated commitment to using data and information proactively to drive and support decision making.
  • The practice involved the public, staff and external partners to sustain high quality and sustainable care.
  • There was evidence of systems and processes for learning, continuous improvement and innovation.

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.

The areas where the provider should make improvements are:

  • Implement regular infection prevention and control (IPC) audits to ensure measures including hand hygiene are effective and embedded.

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