• Doctor
  • GP practice

Archived: Hounsfield Surgery

Overall: Good read more about inspection ratings

Hounsfield Way, Sutton On Trent, Newark, Nottinghamshire, NG23 6PX

Provided and run by:
Dr Katie Moloney & Dr Edward Vipas

Important: The provider of this service changed. See new profile
Important: The provider of this service changed - see old profile

All Inspections

11 November 2020

During a routine inspection

We carried out a comprehensive inspection at Hounsfield Surgery on 11 November 2020. Due to the impact of the COVID-19 pandemic, the majority of evidence reviewed and staff interviews were undertaken remotely in advance of the site visit on 11 November.

The practice had previously received a comprehensive inspection in October 2019 when it received an overall rating of inadequate. The safe and well-led domains were rated as inadequate, the effective domain was rated as requires improvement and the caring and responsive domains were rated good. All population groups were rated as requires improvement. The practice was placed in special measures and two warning notices were also issued against the provider.

We carried out a follow up inspection in January 2020 to check that the provider had addressed the concerns highlighted within the two warning notices. We found that the provider had taken action and the warning notices had been complied with.

You can read the comprehensive and follow up inspection reports by selecting the 'all reports' link for Hounsfield Surgery on our website at www.cqc.org.uk

We undertook this comprehensive inspection in November 2020 to check that the provider had addressed the remaining concerns identified at the comprehensive inspection in October 2019 and to determine if they had made sufficient improvements to be taken out of special measures.

Following our inspection in October 2020, the practice is now rated as good overall. The practice is also rated as good for providing safe, effective, caring, responsive and well-led services and for all population groups.

The service is now rated as good for providing safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

The service is now rated as good for providing effective services because:

  • Patients received effective care and treatment that met their needs.

The service remains rated as good for providing caring services because:

  • Staff treated patients with kindness and respect and involved them in decisions about their care. Patients were very positive regarding the quality of care they received from practice staff.

The service remains rated as good for providing responsive services because:

  • The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way. This had continued during the Covid-19 pandemic.

The service is now rated as good for providing well-led services because:

  • The way the practice was led and managed promoted the delivery of high-quality person-centred care.

I am taking this service out of special measures.This recognises the significant improvements that have been made to the quality of care provided by this service.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 January 2020

During an inspection looking at part of the service

We carried out an announced focussed inspection of Hounsfield Surgery on 22 January 2020. This inspection was undertaken to follow up on breaches of regulations which had been identified at our previous inspection in October 2019 in relation to safe care and treatment and good governance, therefore the practice was not rated at this inspection.

The warning notices that we issued in October 2019 required the practice to achieve compliance with the regulations by 29 November 2019.

The practice is currently rated as Inadequate which remains unchanged until we undertake a full comprehensive inspection of the practice.

Previous reports for this provider can be accessed on our website at www.cqc.org.uk.

At this inspection we found that the requirements of the warning notices had been fully met.

Our key findings across the areas that we inspected for this focussed inspection were as follows:

  • Safeguarding systems had been improved to keep patients safe.
  • Staff checks were taking place which included pre-employment, immunisation records and professional registration.
  • Systems to keep the premises safe and clean had been improved.
  • Care records contained appropriate detail to keep patients safe.
  • Medicines were now safely managed at the practice.
  • Systems for reporting and learning from significant events and acting upon safety alerts were effective.
  • Completed audits contained actions and timescales where appropriate.
  • Staff training and appraisal records had improved.
  • Comprehensive complaints processes were now in place.
  • Policies and procedures were now easily accessible to staff and included duty of candour arrangements.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

10 October 2019

During a routine inspection

We carried out an announced focused inspection at Hounsfield Surgery on 10 October 2019 as part of our inspection programme.

The service was previously inspected in July 2015 and was rated Good overall at that inspection.

We carried out an inspection of this service as we believed there may have been a change in its overall rating since our previous inspection.

Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Effective
  • Caring
  • Responsive
  • Well-led

However, due to findings during the inspection visit we also added the key question of:

  • Safe

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.
  • Appropriate recruitment checks had not been undertaken before employing new staff.
  • Staff immunisation status was not fully monitored.
  • The practice did not have clear systems in place to ensure staff maintained their professional registration.
  • Fire drills and fire training had not been completed by all staff.
  • No risk assessments for the storage of liquid nitrogen or oxygen were available to mitigate the risk of storing hazardous materials.
  • Processes to minimise the risk of infection were not always followed.
  • Medicines were not always safely managed and there was a lack of clinical oversight of the dispensary.
  • The practice did not learn and make improvements when things did not go well.
  • Safety alerts were not always received and acted on appropriately.

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

  • The delivery of high-quality care was not assured by the leadership, governance or culture in place.

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

  • The clinical audit process did not always identify actions or timescales for actions to address areas of shortcoming found by audits.
  • There was no effective system for monitoring or recording staff training and not all staff received regular appraisals.

These areas affected all population groups so we rated all population groups as Requires Improvement.

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

  • Staff treated patients with kindness and respect and involved them in decisions about their care. Patients were very positive regarding the quality of care they received from practice staff.

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

  • The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way.

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.
  • 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.
  • Act in accordance with the Duty of Candour.

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

The area where the provider should make improvements is:

  • Improve complaints information available to patients and review the practice complaints process.

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

29 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hounsfield Surgery on 29 July 2015. Overall the practice is rated as good.

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

  • Information about safety was recorded, monitored, appropriately reviewed and addressed and risks to patients were assessed and well managed.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.

  • Patients were very complimentary about staff at the practice. They said they 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 and easy to understand.

  • Access to the service was consistently rated as good. All of the patients who responded to the national patient survey (published July 2015) said they found it easy to get through to the surgery by phone.
  • Patients we spoke with told us that they could always make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice offered a dispensary service and delivered dosette medicine boxes to vulnerable patients who were housebound.
  • The practice had good facilities for those patients with mobility difficulties 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. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice:

  • The practice had a Dignity Champion who was trained and responsible for ensuring that the 10 key elements of the Dignity Challenge were implemented across all areas of the practice. The induction programme for all new staff included the Dignity Challenge to enable the practice to set standards of behaviour from recruitment. This ensured that Feedback from the GP patient survey was above local and national averages for all indicators including those related to involvement in care and treatment.
  • The GP partner attended meetings with the community falls group and had worked with a local transport company to provide support for patients with a history of falls.
  • One of the GP partners visited the local primary school to introduce young children to the equipment used at the practice and to discuss childhood health issues in a way they understood to reduce any anxieties they might have when visiting their GP at the practice.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Review the criteria for significant events to ensure all dispensing or medicine issues and near misses are included to help to identify any trends or patterns over time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice