We carried out an announced focused inspection at Dr Rex Obonna on 12 April 2019. This was as part of our ongoing inspection programme and to check the practice had made the improvements we said they should when we last inspected the practice in July 2018.

At the last inspection on 3 July 2018, we rated the practice as requires improvement for providing safe services because:

• The arrangements to monitor patients who were prescribed high-risk medicines were not always effective.
• The practice’s system to monitor and record health and safety was not effective and fire safety records were incomplete.

We also rated the practice as requires improvement for providing an effective service for working age people (including those recently retired and students) because:

• Performance in relation to the detection and monitoring of cancer was lower than average.

At this inspection, we found that the provider had satisfactorily addressed these areas, although the practice should make further improvements to ensure they monitor all high-risk medicines.

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 rated this practice as good overall. (Previous rating July 2018 – Good). We rated the practice as good for providing safe services because:

• The practice had improved the way they monitored the health of patients prescribed high-risk medicines.
• They had implemented and improved systems to monitor the risks relating to health and safety and fire safety.

At our previous inspection in July 2018, we told the practice they should review the arrangements for the patient participation group to encourage and act upon the feedback from the group. In April 2019, we also found the practice had tried to improve the arrangements for the patient participation group, to increase membership. They continued to promote the group, both in the practice waiting area and on their website. However, they had failed to recruit any new members. They told us they used other sources of patient feedback, such as surveys, the NHS friends and family tests, complaints and compliments to inform service improvements.

The area where the provider should make improvements is:

• Develop the approach to monitor patients’ health in relation to the use of medicines to include all high-risk medicines.
• Improve the focus of significant event analysis to those which will add value to the practice and better support learning and improvement. Implement a periodic review of significant events to identify trends and themes.
• Take action to increase the uptake of cervical screening to meet the 80% national target.

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 Good overall. (Previous rating July 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Rex Obonna on 3 July 2018 as part of our inspection programme.

At this inspection we found:

• The practice had some systems to manage risk so that safety incidents were less likely to happen. However, there were some areas where the practice needed to make improvements. This included the management of high-risk medicines and the management of health and safety at the practice.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients reported that they were treat with dignity and respect, involved in decisions about their care and treatment and able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• At our previous inspection in July 2016, we told the provider that they should make improvements in some areas. We saw at this inspection improvements had been made. The practice had improved their approach to clinical audit and taken steps so that patients could see a female GP if they wished to. Improvements could still be made in how they shared learning from significant events but some improvements had been made.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients. See the requirement notice at the end of the report for further details.

The areas where the provider should make improvements are:

• Improve the system used to record shared learning from complaints and significant events.
• Evaluate and improve the systems for the referral of patients with suspected cancer and the process in place for reviewing patients once diagnosed.
• Review the arrangements for the patient participation group to encourage and act upon feedback from the group.

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 a previous announced inspection of this practice on 29 September 2015. Breaches of legal requirements were found. Overall, we rated the practice as inadequate. After the comprehensive inspection, the practice wrote to us to say what they would do to address the identified breaches of regulation.

We undertook this comprehensive inspection on 12 July 2016 to check that the practice had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Rex Obonna on our website at www.cqc.org.uk.

Overall, the practice is rated as good.

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

• The practice had received support from the local clinical commissioning group (CCG) and had taken steps to make improvements following the last inspection in September 2015; some of the new arrangements were at an early stage and not fully embedded into the practice. They had developed a clear vision, strategy and plan to deliver high quality care and promote good outcomes for patients.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, learning from significant events was not always effectively identified.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
• Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
• Extended hours appointments were available on a Wednesday between 6pm and 7:30pm.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clearer leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour regulation.

The areas where the provider should make improvements are:

• Continue with the improvements made with clinical audit to ensure that audits are clearly linked to improving patient outcomes.
• Review the arrangements in place to ensure that learning from significant events is always shared and implemented to support patient safety.
• Review the arrangements in place for those patients who wish to see a female GP.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Rex Obonna on 29 September 2015. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The systems in place at the practice were not robust and this resulted in incidents and near misses not always being identified.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Data showed patient outcomes were very low for the locality. Although some audits had been carried out, we saw little evidence that audits were driving improvements to patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice was clean and hygienic and the patients that we spoke with confirmed this.
• Information about services and how to complain was available in reception and easy to understand.
• Urgent appointments were usually available on the day they were requested.
• Governance arrangements at the practice were not sufficient to support the safe management of the practice. The practice did not hold regular governance, clinical or multi-disciplinary meetings, issues were discussed at ad hoc meetings.
• Plans for maintaining the continuity of the business when faced with major disruption were in place but were not effective and required review.
• The practice had sought feedback from patients through its own survey since August 2015; however, no responses had been received. The practice had not reviewed this approach as a result of this lack of uptake. No patient participation group was in place and the practice was not aware of the National GP Patient Survey. Verbal complaints were not recorded by the practice.

The areas where the provider must make improvements are:

• Introduce effective procedures for reporting, recording, acting on significant events, incidents and near misses and ensure that learning is shared with all relevant staff.
• Ensure safety alerts received by the practice are recorded and acted upon appropriately.
• Ensure effective systems are in place for safeguarding children and adults and that the management and recording of significant events and serious case reviews ensures learning and reflection. The practice must ensure records are kept of safeguarding meetings to support patient safety and ensure that when things go wrong lessons can be learned and processes improved.
• Ensure staff receive appropriate training as is necessary to perform their role.
• The registered provider must ensure that the information specified in Schedule 3 is available in relation to each person employed.
• Review the business continuity plan to ensure continuity of service in the event of a major disruption to the service.
• To review the arrangements for clinical audit at the practice. Clinical audit must be linked to patient outcomes and monitored for effectiveness.
• Ensure there are formal governance arrangements in place including ensuring there is sufficient leadership capacity to monitor and deliver improvements. For example, undertaking regular team and clinical meetings and proactively monitoring the Quality and Outcomes Framework (QOF) performance to support practice activity.
• The practice must take steps seek and act upon the feedback from patients to improve its practice. For example, record and respond to complaints received in line with the practices complaints policy. Also, review and take any necessary action following the National GP Survey and the Friends and Family Test. Feedback from patients improves the effectiveness of the practice.

In addition the provider should:

• Review the arrangements for calibration of equipment to include the regular calibration of the thermometer of the dedicated refrigerator as this ensures the safe storage of vaccinations and immunisations.
• Review their Statement of Purpose to make sure it reflects the regulated activity provided.
• Review the register of carers registered as patients at the practice to make sure effective support is provided.
• Take steps to support patients who are hard of hearing to ensure they can access the services provided.
• The practice should review its arrangements for the provision of a patient participation groups (PPG) to ensure the views of patients are acted upon by the practice.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an inspection of this practice on 04 August 2014 during which we found there had been a breach of legal requirements. After the inspection the practice wrote to us to say what they would do to comply with the compliance action (now known as a requirement notice) we set under Regulation 21 HSCA 2008 (Regulated Activities) Regulations (2010) Requirements relating to workers (which corresponds to Regulation 19 of the HSCA 2008 (Regulated Activities) Regulations (2014)).

We undertook this focused inspection on 15 July 2015 to check that the practice had followed their action plan and to confirm they now fully complied with the above regulation. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Rex Obonna on our website at www.cqc.org.uk.

Our key finding was as follows:

• The practice had complied with the requirement notice we had set following the last inspection. Appropriate recruitment checks had been carried out for a member of the clinical team who had commenced working at the practice since our last inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

The practice is based in Southwick Health Centre which is located in Sunderland. The practice is based at The Green, Southwick, Sunderland. It is a small practice with 2096 patients. The practice had not previously been inspected by the Care Quality Commission (CQC) and the provider declared full compliance when it was registered in April 2013. The practice does not have any branch surgeries, so the inspection was focused on this location.

Before the inspection we looked at a wide range of information we held about the practice as well as information the practice sent to us. We asked other organisations, such as the Sunderland Clinical Commissioning Group (CCG) and the local Healthwatch organisation, to share with us what they knew about the practice. We held a listening event where members of the public could tell us about their experiences of GP services within Sunderland. We also asked patients prior to our visit to complete CQC comment cards about their experiences of the service they had received.

We carried out an announced inspection on 26 August 2014. During the inspection we spoke with patients and staff. We also received 15 CQC comment cards completed by patients. Feedback from patients was very positive. They told us they were satisfied with the care and treatment they received. Patients also reported they felt involved in all decisions surrounding their care or treatment, and felt safe using the practice.

The practice had planned its services to meet the needs of the different types of patients it served. Practice staff had made arrangements which helped to protect and safeguard patients. Patients told us they were treated with respect and dignity at all times. Patients also reported they felt involved in decisions surrounding their care or treatment. The practice was clean and hygienic throughout. However, we also identified Disclosure and Barring Service checks had not been carried out for all staff involved in patient care placing them at risk of being cared for by unsuitable staff.  We have therefore found that the practice was in breach of regulation relating to:

*Requirements relating to workers.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.