Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Chatham Street Practice in August 2015 when the practice was rated as inadequate for providing safe and well led services and requires improvement for effective, caring and responsive services. Overall the practice was rated as inadequate and placed into special measures. The service was re-inspected on 5 April 2016 where we found the ratings had not changed and the practice remained in special measures. We carried out a further comprehensive inspection of the practice on 30 September 2016. The overall rating for the practice was requires improvement (safe, effective, caring and responsive) with provision of well-led services rated as inadequate. The practice remained in special measures and was issued with a warning notice for breach of good governance regulations. We returned to conduct a focused inspection on 9 February 2017. At that time the practice had made sufficient improvement to comply with regulations and fulfil the requirements of the warning notice. Both the comprehensive and focused reports of these inspections can be found by selecting the ‘all reports’ link for Chatham Street Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 13 July 2017 to confirm that the practice had sustained the improvements and requirements in relation to the breaches of regulation that we identified in our previous inspection on 30 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for the provision of safe, effective, responsive and well led services and requires improvement for providing caring services. The six population groups have also been re-rated as good following this inspection. Overall the practice is now 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 a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the latest national GP patient survey and an ongoing practice patient satisfaction survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with, and those who completed CQC comment cards, 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 improved and upgraded facilities and was well equipped to treat patients and meet their needs.
• Outcomes for patients diagnosed with long term conditions had improved over the last three years.
• 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

• Ensure fire marshals are appropriately trained to carry out their role.

• Review the practice business continuity plan at appropriate intervals.

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 Chatham Street Surgery on 30 September 2016. The overall rating for the practice at that time was requires improvement. Specifically the practice was rated requires improvement for provision of safe, effective and caring services, good for provision of responsive services and inadequate for the provision of well led services. The practice had previously been rated as inadequate overall in April 2016 and remains in special measures. The full comprehensive report of the September 2016 inspection can be found by selecting the ‘all reports’ link for Chatham Street Surgery our website at www.cqc.org.uk .

This inspection was an announced focused inspection carried out on 9 February 2017 to follow up on a warning notice the Care Quality Commission served following the comprehensive inspection on 30 September 2016. The warning notice was served relating to regulation 17, Good Governance. The timescale given to meet the requirements of the warning notices was 12 January 2017. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. This report covers our findings in relation to those requirements. Due to the focussed nature of this inspection the ratings for the practice have not been updated. We will conduct a further comprehensive inspection within six months of publication of the report of the inspection undertaken in September 2016.

Our key findings were as follows:

• The process to monitor cleaning standards was operated effectively.

• The practice had implemented a secure system for holding blank prescriptions

• Equipment and medicines were in date and fit for use.

• The audit process and programme had been reviewed and an audit plan was in place.

• The practice had implemented an effective system to identify and register patients with caring responsibilities.

• A targeted approach was in place to encourage take up of cancer screening programmes.

• The practice clinical governance structure had been reviewed and an additional partner had been appointed.

• Environmental safety checks were carried out to reduce risk.

At our previous inspection on 30 September 2016, we rated the practice as requires improvement overall and the practice remained in special measures. At this inspection we found that the practice had taken action to address the breach of regulation set out in the warning notice issued in November 2016. However, the practice will remain in special measures until they receive a further inspection to assess the full extent of the improvements achieved since September 2016. If there is not enough improvement we will move to close the service.

Keeping the practice in special measures will give people who use the service the reassurance that the care they get should improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Chatham Street Surgery was first inspected on 5 August 2015. At that inspection the practice was found to have breached regulations and was rated inadequate. The practice was placed into special measures and issued with a warning notice in respect of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Good governance.

A second announced inspection was undertaken on 5 April 2016 to follow up the actions the practice stated it had taken to improve services for patients. Whilst improvements had been made the practice remained rated as inadequate. CQC instituted further enforcement action in accordance with our enforcement procedures. Because six months had elapsed we returned to assess the improvements the practice told us they would make.

Consequently we carried out a further unannounced comprehensive inspection at Chatham Street Surgery on 30 September 2016. Overall the practice is now rated as requires improvement. Specifically it is rated requires improvement for provision of safe, effective and caring services, good for provision of responsive services and inadequate for being well led. (CQC methodology includes for consideration of further enforcement action when a practice in special measures has any one rating of inadequate arising from an inspection).

During the inspection we found improvements made included:

• Staff were clear about reporting incidents, near misses and concerns and there was evidence of learning and communication with staff.

• Care plans were in place, or identified for updating, for those patients that needed additional help and support with their care and treatment.

• A health and safety policy was in place and a range of risk assessments had been completed.

• Appointment systems had been reviewed and updated. This had resulted in an improvement in patient feedback in regard of obtaining appointments at suitable times.

• Patient feedback, from local surveys, had improved in relation to being treated with compassion, dignity and respect. Patients were also positive about seeing or speaking with their preferred GP.

• Patient outcomes had improved and the practice had identified groups of patients who would benefit from additional support and review to better manage their medical conditions.

We also found that:

• Monitoring had not identified risks found in two waiting rooms where trailing wires were present and a failure to secure blank prescriptions in one consulting room.

• There was potential risk to patients because clinical governance systems were weak and relied heavily upon one GP. On call duties were not equitably shared between GPs and

• There was a risk of patients not receiving appropriate advice, treatment and care because information provided from other health and social care providers was not entered in patient records in a timely manner.

• The practice remained dependent on locum GPs which meant that the GP partners were responsible for the majority of management of clinical governance systems and processes.

• Whilst the practice had identified the need to improve standards of cleanliness these had not been achieved. Inspectors found two areas of the practice where appropriate cleaning standards had not been met.

• Staff understanding of the processes and procedures required by law to assess the capacity of patients to understand and consent to care and treatment was inconsistent.

• Audits were undertaken but only one of these had resulted in follow up to check whether action had been taken to improve patient outcomes.

The areas where the provider must make improvements are:

• Ensuring the systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activities are operated effectively. Putting in place governance arrangements that enable systems to be managed and reviewed to ensure the needs of the registered patients are met.

• Ensure the systems for assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated are operated consistently.

• Ensure that care provided is person centred taking account of the patients’ ethnicity, vulnerability and preferences.

• Ensuring that patients are given opportunities to make informed choices regarding their care including the benefits of taking up health promotion and prevention of ill health opportunities.

The area where the provider should make improvement is:

• To implement an effective system to promote the benefits of registering as a carer with a view to increasing the number of carers registered.

This service was placed in special measures in August 2015. Insufficient improvements have been made such that there remains a rating of inadequate for provision of well led services. However, improvements have been made in other areas of service provision. We are therefore keeping the practice in special measures. 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 varying the provider’s registration 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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chatham Street Surgery on 5 April 2016. This comprehensive inspection was carried out to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.

Our previous inspection in August 2015 found breaches of regulations relating to the safe, effective, caring and responsive delivery of services. There were also concerns and regulatory breaches relating to the management and leadership of the practice, specifically in the well led domain. The overall rating of the practice in August 2015 was inadequate and the practice was placed into special measures for six months.

During the inspection in April 2016, we found evidence of minor improvements having been made. However, the practice continues to be rated as inadequate overall due to the unsatisfactory levels of improvement. Specifically it is rated inadequate for the provision of safe and well led services and requires improvement for provision of effective, caring and responsive services. Our rating of inadequate for the provision of well led services reflects the failure of leadership and management to deliver significant progress in improving services across the board for all patient groups.

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

• The practice did not have a clear leadership structure. There was insufficient leadership capacity and limited formal governance arrangements. The practice did not have a culture of risk management and was reactive to improvement in services and failed to demonstrate a drive for constant and sustainable improvement.

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and systems to ensure action had been taken in regard to national safety alerts were ineffective.

• Feedback from patients was encouraged but the response to feedback was limited. For example, the practice had appointed additional nursing staff to increase appointment capacity but did not demonstrate a commitment to address feedback relating to unhelpful reception staff or an inefficient appointment system.

• Data showed patient outcomes, particularly for patients with long term conditions, had improved. However, we found care plans to support patient outcomes were not always in place or effective. In a number of cases, there was little evidence to confirm patients had been involved with the development of their care plan.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Appointment systems were not working well so patients did not receive timely care when they needed it.

The areas where the provider must make improvements are:

• Ensure all actions required in response to national safety alerts are completed and recorded.

• Take action to address identified concerns with monitoring of cleaning standards throughout the practice premises.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure all risks to patient safety are identified and action taken to reduce risk. For example, in keeping liquid nitrogen at the practice and in assessing the risk of legionella and the safety of the practice premises.

• Ensure the planned clinical audits, including re-audits, take place and inform improvements in patient outcomes.

• Ensure care plans are appropriately recorded and involve the patient in the development of their care plan.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements

• Improve processes and access for making appointments.

The areas where the provider should make improvements are:

• Review and ensure carers are encouraged to register as such to enable them to access the support available via the practice and external agencies.

This service was placed in special measures in August 2015. Insufficient improvements have been made such that there remains a rating of inadequate for the delivery of safe and well led services. This led to a continued rating of inadequate. 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. The service will be kept under review whilst we complete our action and if needed this could be escalated to urgent enforcement action.

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 Chatham Street Surgery on 5 August 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe services and being well led. The population groups for older people, people with long term conditions, families children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health were rated as inadequate based on the overall rating of the practice. Improvements were also required for providing caring, responsive and effective services.

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

• Most of the patients we spoke with were very satisfied with access to appointments and told us that they were very happy with the service, the GP and the staff.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity. However patients told us that the use of locum GPs meant they did not receive continuity of care and this caused them some concern.

• The practice had a dedicated care co-ordinator providing support to patients and carers of patients through community settings to enable patients to live independently for longer.

• CQC comments cards provided positive feedback; however the GP patient survey results, reviews left on public websites were not always positive. The proportion of patients who would recommend their GP surgery was 52% which was among the lowest for the area.

• Systems and processes were not always in place to keep patients safe from the risk of harm. We found significant concerns in medicines management. The practice did not have robust systems for checking and recording fridge temperatures. The practice did not have adequate systems in place to ensure practice nurses administered vaccines using directions that had been produced in line with legal requirements and national guidance.

• The practice had a limited plan to manage unforeseen circumstances and maintain business continuity.

• Patient outcomes are below average for the locality. Patients' needs were not always assessed but some audits to identify improvements to patient care had taken place.

The areas where the provider must make improvements are:

• Ensure medicine management systems are reviewed and reflect national guidelines. Including, the recording and monitoring of refrigerator temperatures and the development of a cold chain procedure.
• Review and implement more effective systems to identify, assess, and manage risks relating to the health, welfare, and safety of patients, and others who may be at risk.
• Ensure staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out their duties they are employed to perform including providing clinical care and treatment in line with national guidance and guidelines.

In addition the provider should:

• Review patient care plans to ensure these are reviewed regularly and the individual patient is involved in developing the plan. This includes recording their preferences and decisions for care and treatment.
• Review how patient safety alerts and other safety guidance are disseminated within the practice.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chatham Street Surgery on 27 February 2019 as part of our inspection programme.

At the last inspection in February 2017 we rated the practice as Good overall.

At this inspection we found the practice had not sustained the improvements we found at our last inspection. It is now rated as requires improvement in provision of both effective and well led services. Consequently, the practice is now rated as requires improvement overall.

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

• There was limited monitoring of the outcomes of care and treatment.
• Some performance data was significantly below local and national averages.
• The practice could not demonstrate how they intended to improve uptake of childhood immunisations and cancer screening.

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

• The overall governance arrangements were operated inconsistently.
• The practice did not have clear and effective processes for managing risks, issues and performance.

We rated the practice as good for providing safe, caring and responsive services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The area 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).

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care