We carried out an inspection at Longfleet House Surgery in September 2017. The overall rating for the practice was inadequate and the practice was placed into special measures. Following the inspection two warning notices were served which related to regulations 12 Safe care and treatment and 17 Good governance of the Health and Social Care Act 2008. A requirement notice was service for regulation 12 Safe care and treatment.

We carried out a focused inspection in November 2017 to check whether they practice had met the warning notices. We deemed the warning notices to be met at this inspection.

We carried out an announced comprehensive at Longfleet House Surgery on 16 May 2018, to follow up on the requirement made at our inspection in September 2017. We deemed the requirement notice to be met, but found other areas of concern, notably:

• Shortfalls in the provision of training deemed as necessary by the practice.
• The availability of nursing staff was limited to a set number of days per week.
• The practice was unable to demonstrate fully that appropriate recruitment checks had been carried out for all staff who worked at the practice.
• There were risks of delays in reviewing of patient test results when a GP was absent.

This service was placed in special measures September 2017 and has remained in special measures as insufficient improvements were made.

These reports can be found by selecting the ‘all reports’ link for Longfleet House Surgery

on our website at

www.cqc.org.uk

.

We carried out an unannounced comprehensive inspection at Longfleet House Surgery on 30 January 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 16 May 2018.

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:

• We found that all required information was available, apart from evidence of satisfactory conduct in previous employment for one of the permanent members of staff.
• Blood glucose monitoring machines were last recorded as having control testing carried out in May 2018. Practice policy and best practice guidance recommends at least quarterly testing. The practice were signed up to the clinical commissioning groups system for testing with control liquids, to ensure readings were accurate.
• There were not records available to demonstrate that weekly testing of fire alarms had been carried out.
• At this inspection in January 2019 we found that there were still no overarching health and safety risk assessments. However, shortfalls identified at our previous inspection had been addressed.
• The practice had safeguarding information leaflets; the information was aimed at healthcare professionals and may not have been relevant for patient need. The same information was also on the practice’s website. We were provided with documentation after the inspection which showed that a gas safety check had been carried out in February 2019.
• There were shortfalls in Legionella management. We found that water temperatures and bacteria analysis had been carried out. However, the practice could not fully demonstrate that all risks had been minimised as far as possible. Records related to weekly flushing through of little used outlets were incomplete.

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

• All training deemed necessary by the practice had been completed, apart from one member of staff who required infection control and basic life support training; one member of staff who requires infection control training; and one member of staff who required basic life support training. We saw that this had been planned for.
• The locum practice nurse works two days a week and was able to carry out wound dressings, blood tests, BPs checks and aspects of long term condition reviews. They were not able to carry out cervical screening, but arrangements were in place for patients to attend a sister practice if needed. Reception staff said at present there was a waiting list for cervical screening, but did not give a figure. They were aware of the work that the locum nurse could undertake.
• Some performance data continued to be below local and national averages. The overall trend was one of improving performance, but staffing arrangements did not allow for practice monitoring of the outcomes of care and treatment.

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

• The practice did not address feedback from patients in a proactive manner.

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

• The service offered was limited due to the skills and competencies of staff available.

The practice had not made adequate improvements since our previous inspections. Therefore, the practice remains rated as inadequate for providing well-led services because:

• The practice had experienced staff leaving and had not been able to recruit into these roles, partly due to national shortages of skilled staff. There were shortfalls in the provision of management hours to enable good governance of the practice which potentially impacted on risk management processes.
• The registered manager was also responsible for other GP practices and therefore had other responsibilities in addition to overseeing Longfleet House Surgery, this had impacted on governance arrangements for the practice.
• There were shortfalls in reviewing policies and procedures to ensure information was accurate and relevant, for example the business continuity plan.
• The business continuity plan was last reviewed in March 2018, but had not been reviewed to take account of staff leaving the practice.

These areas affected all population groups so we rated all population groups as requires improvement, apart from people with long-term conditions, which was rated as inadequate due to no sustained improvement in monitoring outcomes for patients.

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.

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

The areas where the provider should make improvements are:

• Review staff recruitment files to ensure they have all the required information.
• Review records related to equipment calibration, fire alarm testing and Legionella management so they are complete.
• Review information contained in safeguarding leaflets and on the practice website, so it is relevant for patients.
• Continue to ensure that staff training is kept up to date.
• Review arrangements for providing cervical screening uptake.
• Continue to work on monitoring and improving outcomes for patients.

This service was placed in special measures in September 2017. Insufficient improvements have been made such that there remains a rating of inadequate for well led. 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.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an inspection at Longfleet House Surgery on 8 and 13 September 2017. The overall rating for the practice was inadequate and the practice was placed into special measures. The full comprehensive report can be found by selecting the ‘all reports’ link for Longfleet House Surgery on our website at www.cqc.org.uk.

Following the inspection two warning notices were served which related to regulations 12 Safe care and treatment and 17 Good governance of the Health and Social Care Act 2008. Shortfalls were identified in relation to:

Assessment, monitoring, management and mitigating risks to the health and safety of patients who used the service. In particular:

• Failure to identify risks associated with a lack of GP appointments
• A lack of risk assessments in relation to water safety; fire safety; and lone working.

Systems and processes to enable the registered provider to assess, monitor and improve the quality and safety of services provided were not adequate. There were shortfalls in governance arrangements to support the delivery of good quality care including:

• Lack of clear clinical leadership.
• Acting on pathology and cervical smear results.
• Staff training and appraisal arrangements.
• Ensuring an adequate number of appointments were available.
• Acting on feedback from staff and patients.

This inspection was an announced focused inspection carried out on 29 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the warning notices served after our previous inspection on 8 and 13 September 2017. This report covers our findings in relation to those warning notices only.

Our key findings were as follows:

Systems and processes to enable the registered provider to assess monitor and improve the quality and safety of services provided had improved.

• Safeguarding policies were in place and were accessible to staff on the shared drive of the practice’s computer system.
• A risk assessment had been put into place for when there was a sole clinician working on the premises.
• Risk assessments for fire safety and legionella control had been reviewed an updated. Actions had been taken to minimise risk; with the exception of details how to keep people safe if the exits from the first floor were blocked preventing escape.
• There was information on staff roles and responsibilities and who the clinical lead GP was.
• Staffing levels were reviewed and planned for. The practice nurse position was vacant and being recruited into and until this happened a practice nurse from another practice provided appointments on two mornings per week. An advanced nurse practitioner also provided appointments all day on Tuesdays.
• The practice had recommenced extended hours appointments on a Monday evening, since a salaried GP had been recruited in October 2017. However, the practice website had not been updated to reflect this, at the time of inspection, this has now been done.
• Verbal as well as written complaints had been recorded.
• Pathology and cervical screening test results were now being handled in a timely manner and acted upon.
• Systems for staff training and appraisals were in place.
• The appointments system had been reviewed and urgent on the day appointments and routine bookable appointments were available.
• A schedule for meetings had been introduced to sharing learning and good practice, but meeting minutes did not fully demonstrate actions taken and ongoing monitoring.
• A staff survey had been carried out and was due to be fully analysed followed by an action plan place to address concerns raised.

• Work had started on engaging with the patient participation group.

The provider should:

Further develop systems for maintaining an oversight of shared learning as well as training provision to include when overdue training would be provided and how it would be monitored.

The Care Quality Commission has found that improvements have been made and the warning notices are met.

The full report published on 21 November 2017 should be read in conjunction with this report. The practice remains in special measures until a full comprehensive inspection is carried out by the Care Quality Commission. Therefore the overall rating remains inadequate.

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 Longfleet House Surgery 3 December 2015. 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.
• 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, although not always with the same GP. 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 areas where the provider should make improvement are

• Review risk assessment processes for staff deemed not to require a DBS check.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as inadequate. (Previous inspection September 2017 and November 2017 – inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Inadequate

We carried out an inspection at Longfleet House Surgery on 8 and 13 September 2017. The overall rating for the practice was inadequate and the practice was placed into special measures. Following the inspection two warning notices were served which related to regulations 12 Safe care and treatment and 17 Good governance of the Health and Social Care Act 2008.We carried out a focused inspection on 29 November 2017 to check whether they practice had met the warning notices. These reports can be found by selecting the ‘all reports’ link for Longfleet House Surgery on our website at www.cqc.org.uk.

We carried out an announced comprehensive at Longfleet House Surgery on 16 May 2018.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• Although there had been improvements in training provided for information technology systems and chaperone training, we identified shortfalls in the provision of fire safety; learning disability and mental health awareness; consent; privacy and dignity and dementia awareness training. Which were all areas that the practice considered to be mandatory.
• There were notices in the waiting area regarding having one problem for one appointment and a list of what medicines would not be prescribed as determined by the local clinical commissioning group.
• The availability of nursing staff was limited to a set number of days per week.
• The practice was unable to demonstrate fully that appropriate recruitment checks had been carried out for all staff who worked at the practice. There was a lack of information held at Longfleet Surgery for staff that had contracts with other employers and were released to work at Longfleet Surgery.
• The practice was reliant on staff that were not permanently employed by the practice or contracted for a specific number of sessions.
• There were risks of delays in reviewing of patient test results when a GP was absent.
• Staff involved and treated patients with compassion, kindness, dignity and respect.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

This service was placed in special measures September 2017. Insufficient improvements have been made such that there remains a rating of inadequate for well led. Therefore we are therefore considering our options in line with our enforcement procedures. The service will remain in special measures and be kept under review.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice