We carried out an announced comprehensive inspection at Poplar House on 6 December 2018 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor.

At the last inspection published in September 2015 we rated the practice as good overall.

Our judgement of the quality of care at this service is based 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.

The practice is rated as good overall.

We rated the practice as

requires improvement

for providing safe services because:

• The practice did not have safe and effective systems and processes to recruit staff.

This means that:

• People who used the service were generally protected from avoidable harm and abuse, however legal requirements in relation to recruitment of staff, were sometimes not met.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• Patients’ needs were met by the way in which services were organised and delivered.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.

There were areas where the provider

must

make improvements:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed. Ensure specified information is available regarding each person employed.

There were areas where the provider

should

make improvements:

• Improve the recording and documentation of discussions at safeguarding meetings.
• Improve management oversight of professional registration, staff immunisations and medical safety alerts.
• Improve the records kept in relation to complaints to include those made verbally.

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

This is a focused desktop review of evidence supplied by Poplar House Surgery to demonstrate how they have improved the service in the key question Well Led.

Overall, the practice is rated as good. Following this focused desktop review of the practice, we found the practice to be good for providing Well Led services.

Poplar House Surgery was inspected on the 3 February 2015. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection, the GP practice was rated ‘good’ overall. However, for the key question Well Led, systems to monitor and assess the quality of service and ensure staff were appraised and supported were assessed as ‘requires improvement’. The practice was not meeting the legislation in place at that time, (Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service providers).

The practice submitted an action plan with timescales telling us how they would ensure they met the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010. They supplied us with a range of documents that demonstrated they were now meeting the requirements of the 2010 regulations and the new legislation that has superseded this, (Regulation 17 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance).

Evidence supplied included copies of clinical audits, evidence of infection control monitoring and a staff appraisal meeting timetable. In addition, the practice submitted their business continuity plan, their 2015 schedule of internal and external multi-disciplinary team meetings and information on the actions taken to improve telephone services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We had previously undertaken a responsive inspection at this practice in September 2014 due to information of concern we had received. A number of improvements were required and we issued compliance actions and warning notices at that time.

We carried out an inspection of Poplar House Surgery on 3 February 2015 as part of our new comprehensive inspection programme and to determine the actions taken since the last inspection.

Overall the practice is rated as Good.

Our key findings were as follows:

• Significant improvement had been made to ensure staff worked together as a cohesive team.

• Improvements had been implemented for the safe and effective recruitment and employment of staff.

• The practice had significantly improved the system in place for reporting, recording and monitoring significant events.

• The practice was clean and the environment and equipment appropriately maintained.

• The GPs, nursing staff and Pharmacist were familiar with and used current best practice guidance to maximise outcomes for patients.

• The practice had an active Patient Reference Group. Minutes of meetings and annual reports were made available on the practice website. We were told the practice was improving in how they responded to comments and feedback to improve services.

• Patients we spoke with and comments made by patients via the CQC comment cards reflected that they felt staff were caring and tried their best to help.

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

Importantly, the provider must:

• Effectively monitor and assess the quality of the service provided.

• Undertake staff appraisals in order to identify personal development and monitor individual staff performance.

.

In addition the provider should:

• Take action to improve telephone access to the practice.

• Undertake appropriate monitoring of infection prevention and control within the practice.

• Ensure that all staff have access to a paper copy of the practice business continuity plan.

.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Poplar House Surgery is registered with the Care Quality Commission (CQC) to provide the regulated activities of: diagnostic and screening services; family planning; maternity and midwifery services, treatment of disease, disorder or injury.

This inspection is a result of concerns raised with the CQC and are findings are:

There is no clear leadership of the practice. A lack of formal governance systems meant the monitoring of quality and identification and management of risks within the practice are ineffective. Leadership is neither visible or accessible. As a result teams work in isolation and often in a chaotic and dysfunctional way although a shared commitment to the care and welfare of patients is evident. Policies and procedures are either not in place, lack detail or require updating.

Systems and procedures to ensure the practice is safe are inadequate. There is a lack of evidence to show the practice learned from incidents. Systems to monitor safety and reduce risk are ineffective.

The practice has a Patient Representation Group (PRG). The Chair reported the practice is responsive to ideas from the group and their contribution is welcomed and valued. Response to a patient survey carried out by the practice in February 2014 in collaboration with the PRG shows that overall 85.5% of patients who responded are happy with the care they receive.

The practice does not have appropriate procedures in place to demonstrate staff are safely recruited and employed.

The practice does not have consistent systems in place to verify the training and competencies of staff or to demonstrate the skill and experience necessary for their roles and responsibilities.

The practice is not meeting regulation 10 of the Health and Social Care Act 2008: Assessing and monitoring the quality of service provision.

The practice is not meeting regulation 21 of the Health and Social Care Act 2008: Requirements relating to workers.

The practice is not meeting regulation 23 of the Health and Social Care Act 2008: Supporting 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.

Professor Steve Field

Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Poplar House Surgery on 06 December 2018 as part of our inspection programme. We rated the practice as requires improvement for providing safe services and good overall.

The full comprehensive report following the inspection in December 2018 can be found on our website here: https://www.cqc.org.uk/location/1-541769355

At our inspection in December 2018, we rated the practice as requires improvement for providing safe services because:

• The practice did not have safe and effective systems and processes to recruit staff.

On 25 March 2019 we undertook a focussed inspection of the safe key question. We visited the practice to confirm it had carried out the plan to meet the legal requirements in relation to the breach in regulation identified in our previous inspection in December 2018. This report covers our findings in relation to that requirement.

At this inspection, we found that the provider had satisfactorily addressed the legal requirement and any suggestions for improvements.

We have rated this practice as good for providing safe services.

We found that recruitment procedures had been established to ensure only fit and proper persons are employed. This provided assurance that staff employed at the practice had been recruited in a safe way.

We also found that improvements had been made to:

• The recording and documentation of discussions at safeguarding meetings.
• The oversight of professional registration and staff immunisations.
• The records kept in relation to complaints to include those made verbally.

There were areas where the provider should make improvements:

• Obtain evidence of medical indemnity for locum practitioners to gain assurance that appropriate cover is in place.

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