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 Elmdene Surgery on 15 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events and learning from these was discussed and shared.
• Risks to patients were assessed and well managed, including an infection control audit with identified actions.
• Medicines were well-managed within the practice.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained and had received updates to training 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 and the practice was open and transparent in responding to complaints and concerns.
• Most patients we spoke with said they found it easy to make an appointment and that there were 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 provider was aware of and complied with the requirements of the duty of candour.
• The patient participation group was actively looking to recruit new members after a period of dormancy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with patient's who used the service, staff, nurses and doctors. People told us that they were happy with the service they received. One person told us, "I’ve no complaints at all". Another person told us, "They’re so nice here. Well run and very friendly" and “I have nothing but praise for what is a superb, professional and friendly service”.

We found that there was a policy for safeguarding children, young adults and vulnerable adults in place. We saw that there were contact details for referrals displayed in communal areas regarding both child protection and vulnerable adults, informing patients how to report safeguarding issues should they need to.

We found that the service had policies and procedures in place for infection control. Staff told us that all instruments used in the practice were single use devices only. We spoke with one of the staff members regarding their understanding of decontamination procedures in the surgery. The description for the decontamination processes was explained to us and was in line with Decontamination Guidelines.

We found that patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We viewed the medication management policy and saw that this provided clear directions for items such as pharmacy procedures, adverse reactions to drugs, monthly checks for expiry dates, and management of any errors.

The provider had suitable processes for the recruitment of all staff and the provider had a system in place to ensure that staff were not employed without suitable pre-employment checks being carried out.

We found that patients and their representatives were regularly asked for their views about their care and treatment. This was achieved using a variety of methods. For example via the provider’s Patient Participation Group, using a website feedback form and a comments box in reception. We looked at the results of the most recent surveys and found that most people had given the practice a score of nine out of ten or ten out of ten for things such as: Were they treated with respect and courtesy and the quality of the care received from doctors/nurses. Comments included “The surgery offers a very good doctor, nurse and staff relationship with it's patient.” and “The level of care and expertise is excellent”. We saw that the questionnaires/surveys had been reviewed, analysed and action taken.

This practice is rated as inadequate. (The practice was previously inspected in June 2016 and was rated as good)

The key questions 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 responsive comprehensive inspection at Elmdene Surgery on 12 July 2018 in response to changes at the practice and concerns. For example, one partner left the practice in May 2018, two complaints have been received by CQC in quick succession regarding difficulties accessing care and treatment and there has been insufficient management infrastructure for approximately two years.

Elmdene Surgery has experienced significant growth with the registered patient list size growing by 50% in a two year period, from 6000 patients in 2016 to 9100 patients in 2018. The practice has failed to adequately respond to this challenge. There has been insufficient management infrastructure and insufficient leadership capacity and capability. There are significant concerns regarding the two dispensaries at the branch surgeries of this practice, which both lack leadership oversight and governance and do not operate safely.

A warning notice regarding the breach of the Health and Social Care Act 2008, Regulation 17, Good Governance, was served on the practice.

At this inspection we found:

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice did not consistently learn from them or improve their processes.
• Lack of skilled and qualified management staff increased the risks to people who use services.
• Staff had the information they needed to deliver safe care and treatment to patients.
• The practice did not have reliable systems for appropriate and safe handling of medicines, including in the two dispensaries.
• The practice did not have a comprehensive programme of quality improvement activity and did not consistently review the effectiveness and appropriateness of the care provided.
• Staff had the skills, knowledge and experience to carry out their roles.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients reported that the appointment system was easy to use, but that there were sometimes difficulties in accessing the practice by telephone.
• Leaders did not have the capacity to deliver high-quality, sustainable care.
• The provider was receptive to the findings of the inspection and the lead GP partner was immediately responsive, sending documents to show steps towards mitigation of risk and improvement.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure that there are effective systems and processes established to ensure good governance.
• Ensure that there is sufficiently qualified and experienced management at the practice.

The areas where the provider should make improvements are:

• Review their recruitment policy so that it is in line with regulation.
• Review the lone working procedure for all staff to help mitigate risk.
• Review and improve the support they offer to carers.

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