We carried out an announced comprehensive inspection at Denmark Road Surgery on 5 March 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 15 August 2018, where the practice had been rated as inadequate, with safe, effective, and well-led domains rated as inadequate, and caring and responsive domains rated as requires improvement. At this inspection we found that there remained insufficient leadership of practice management to ensure consistent and effective governance. The practice therefore remains rated as inadequate for being well-led, and remains in special measures.

We first inspected the practice in December 2016 where the safe and well-led domains were rated as good. We did not rate the effective, caring or responsive domains as at that time the provider did not have any external performance data.

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 rated the practice as requires improvement for providing safe services because:

• The practice had strengthened a number of systems and processes to manage risks to patients.
• However, some of those systems were not operating effectively and so there remained some risks, particularly associated with the practice premises, that had not been well managed.

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

• Staff had received training and support required for their role.
• The practice had implemented action plans to address areas where patients did not receive good care and treatment.
• However, some performance data was still significantly below local and national averages/national targets.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

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

• There was not sufficient monitoring to ensure that changes made to telephone arrangements had improved the patient experience.
• The practice was not responding effectively to patient feedback.

These areas affected all population groups so we rated all population groups as requires improvement.

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

• Although the practice had made improvements since the last inspection, there remained insufficient leadership of some areas of practice governance, particularly related to safety.
• There were a number of systems that had incomplete or inaccurate data or were not operating effectively.
• The practice had improved its clinical performance, but some areas were still below average or below target.
• 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 clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We served warning notices following the last inspection for breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The inadequate rating takes into account the evidence from this inspection and the fact that the provider has not fully rectified the issues following the previous enforcement action.

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 areas where the provider should make improvements are:

• Take action to improve how young patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

This service was placed in special measures in October 2018. Insufficient improvements have been made such that there remains a rating of inadequate for a key question. Therefore, we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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

This practice is rated as Inadequate overall. (Previous rating December 2016 – Not sufficient evidence to rate)

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Denmark Road Surgery on 15 August 2018 as part of our planned inspection programme. The practice was newly-formed at the time of the last inspection in 2016, and so there was not enough evidence to give the practice a rating for each key question or an overall rating. In 2016, we rated the practice as good for being safe and being well-led.

At this inspection we found:

• The practice had not adequately assessed and mitigated a number of risks, including those related to fire, infection control and substances hazardous to health.
• There was not an effective system to ensure learning and improvement after things went wrong.
• There were areas where the care of patients was below average. In some of these, evidence provided by the practice showed that performance had deteriorated further from 2016/17 (the last published data). There were no documented action plans in place to address these at the time of inspection.
• There was no effective system to ensure that all staff received the training and support required for their roles.
• There were not effective systems to identify patients who needed support and to ensure that it was provided.
• The practice had not acted effectively on longstanding feedback that patients found it difficult to get through to the practice by telephone.
• The complaints policy was not in line with recognised guidance and complaints were not managed in line with the timescales advertised. There was little or no evidence of improvement following complaints.
• There was insufficient leadership of some areas of practice governance, particularly related to safety and the management of staff.
• Systems had been established but had not been monitored to ensure they were working effectively. Some processes were not clearly set out or effective.

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.
• 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:

• Take action to improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
• Take action to improve the uptake of cancer screening.
• Take action to improve arrangements for managing confidentiality at the reception desk.

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.

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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Denmark Road Surgery on 19 July 2016. The practice does not have an overall rating at this stage, as the practice has not been operating for a sufficient time for effective, caring and responsive to be rated.

We had previously conducted an announced comprehensive inspection of the practice’s predecessor Woodside Group Practice on 2 September 2015. As a result of our findings during that visit, the practice was rated as good for being safe and caring, requires improvement for being effective and responsive, and inadequate for being well-led. This resulted in a rating of requires improvement overall. We found that the provider had breached a regulation of the Health and Social Care Act 2008; Regulation 17 (1) (2) good governance, and because they had not made sufficient improvements since their last inspection we took the decision to place the practice into Special Measures. The providers decided to close the previous practice and two new locations (one of which is Denmark Road Surgery) were formed under two new partnerships which are registered separately with the Care Quality Commission. We inspected Denmark Road Practice three and a half months after they began providing care.

Our key findings across all the areas we inspected at Denmark Road Surgery on 19 July 2016 are as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The provider was aware of and complied with the requirements of the duty of candour.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named 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.
• 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 areas where the provider should make improvement are:

• Ensure a programme of quality improvements, including clinical audits, is established.

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Continually monitor feedback from patients, and clinical performance in relation to the Quality and Outcomes Framework, and make improvements wherever these are identified.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice