We carried out an announced comprehensive inspection at Dr Abiodun Obisesan on 18th December 2018 to check that improvements that had been identified at our inspection of 1st August 2017 had been sustained.

The practice had been placed into special measures following our inspection of 9th August 2016. The inspection of 1st August 2017 was a comprehensive inspection to ensure that improvements had been made. At that time, the practice was taken out of special measures and rated as good overall, with requires improvement for providing responsive services and also requires improvement for patients with long-term health conditions. This was because performance in respect of an atrial fibrillation and some diabetes indicators were below average. Further, patient feedback was below average in respect of access.

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 good overall.

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

• There were not effective systems to disseminate information from patient and medicine safety alerts to the relevant staff.
• The policy to manage changes to medicines from other providers was not always followed by staff.
• Not all medicines that were prescribed and supplied by other providers were included in the patient’s clinical records. This had been highlighted in our previous report in December 2017.

We have rated the practice as good for providing effective, caring, responsive and well-led services and across all population groups because:

• Patients received effective care and treatment that met their needs.
• 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.
• Improvements had been made to ensure that patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Systems required review to ensure that patients with atrial fibrillation were coded correctly.
• Data evidenced that improvements had been made in respect of diabetes indicators.
• Whilst there was a record of staff immunisations in individual records, there was no central record of this.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Review the records of patients with atrial fibrillation to ensure that these are accurate.
• Maintain a central record of staff immunisations.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 9th August 2016, we carried out a comprehensive announced inspection at Dr Abiodun Obisesan, also known as Winstree Medical Practice. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, effective and well-led services and requires improvement for providing caring and responsive services. As a result of the overall inadequate rating, the practice was placed into special measures for six months.

Following the inspection in August 2016 we issued the practice with a warning notice. The practice was required to be compliant with the warning notice by 16 March 2017. We conducted a focused inspection at the practice on 23 May 2017 to establish whether the requirements of the warning notice had been fulfilled. We found that the requirements of the warning notice had been met.

Both inspection reports can be found by selecting the ‘all reports’ link for Dr Abiodun Obisesan on our website at www.cqc.org.uk.

We then carried out a comprehensive inspection on 1st August 2017. The practice is now rated as good overall.

• Staff were able to recognise and report significant incidents. These were investigated and lessons learnt identified and shared during clinical and practice management meetings.
• Staff were aware of current evidence based guidance which was discussed at a weekly clinical meeting. Meeting minutes evidenced discussion and learning.
• Systems had been significantly improved in relation to the management of medicines. Patients taking high risk medicines were being effectively identified, recalled and monitored.
• There was an effective system of audit. These were targeted to improve and monitor performance or respond to safety incidents and alerts.
• The practice had reduced their exception reporting rate which was now in line with local and national averages.
• There were now safe recruitment processes. Relevant staff had received a Disclosure and Barring Service check.
• Most areas of clinical and non-clinical practice that required improvement had been identified and appropriate actions had been taken.
• The monitoring of patients with some long-term conditions required improvement.
• Policies, procedures and risk assessments had been updated.
• There was an action plan to respond to and action patient feedback. This was continually reviewed to assess the changes made.
• Results from the national GP patient survey published in July 2017 showed that patient’s satisfaction with how they could access care and treatment were lower than local and national averages.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• 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.
• Significant and meaningful improvements had been made. Systems were put in place so that there was a continuous cycle of review, action and improvement.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

The areas where the provider should make improvement are:

• Continue to review and improve performance in accordance with the findings of the GP patient survey.
• Continue to review and improve systems to monitor patients taking Warfarin.
• Continue to improve systems to record medicines prescribed by other providers
• Continue to make improvements in relation to long-term conditions quality standards.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 9th August 2016, we carried out a comprehensive announced inspection at Dr Abiodun Obisesan, also known as Winstree Medical Practice. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, effective and well-led services and requires improvement for providing caring and responsive services. As a result of the overall inadequate rating, the practice was placed into special measures for six months.

We issued the practice with a warning notice in relation to the governance at the practice. The issues of concern can be summarised as follows:

• A lack of suitable systems and processes in place for the management of medicines, including the obtaining, prescribing, recording, handling, storing and security of these.
• An absence of established safe recruitment processes; for example, not all clinical staff had received a DBS check and chaperones were not routinely DBS checked or risk assessed to identify whether or not this was required.
• Inadequate systems to assess, monitor and improve performance at the practice.
• Inadequate or incomplete policies, procedures and risk assessments.
• No system to ensure patients taking high risk medicines were receiving the requisite blood tests and monitoring.

The practice was required to be compliant with the warning notice by 16 March 2017. We conducted a focused inspection at the practice on 23 May 2017 to establish whether the requirements of the warning notice had been fulfilled. We found:

• Systems had been significantly improved in relation to the management of medicines.
• There were now safe recruitment processes. Relevant staff had received a DBS check.
• Areas of clinical and non-clinical practice that required improvement had been identified. Appropriate actions had been taken.
• Policies, procedures and risk assessments had been updated.
• Patients taking high risk medicines were being effectively identified, recalled and monitored.

The practice had complied with the requirements of the warning notice although the practice will remain in special measures until the outcome of their comprehensive inspection which will take place later in 2017. Services placed in special measures are inspected within six months of the date of the publication of the report which placed them into special measures. 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.

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 Abiodun Obisesan, also known as Winstree Medical Practice on 9 August 2016. Overall the practice is rated as inadequate.

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

• There was a system in place for reporting and recording significant events which were discussed at practice meetings, although there was little evidence of the learning discussed.
• Some policies were incomplete, identified the incorrect lead clinician or were not easy to locate.
• Recruitment checks were not being undertaken consistently and in line with legislation and guidance. Staff carrying out chaperone duties had not received a disclosure and barring service check or a risk assessment as to why one was not necessary.
• The practice did not have adequate systems to manage medicines.
• There was a dispensary located at the branch surgery. Not all controlled drugs were not being recorded in line with legislation and there was no system to record or investigate near misses.
• Some medicines were stored at the main surgery. A risk assessment had not been carried out for the safe storage of these medicines. Room temperatures were not being monitored to ensure these were stored within the recommended range. We found out of date medicines in one of the treatment rooms and prescription stationery not being stored in line with national guidance.
• At both the branch and main practice, the temperatures of fridges used for the storage of vaccines were not being monitored and specialist fridges were not being used.
• The system for reviewing patients taking medicines that required monitoring was not effective. This included patients on high risk medicines.
• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were below or in line with the national average, including those which related to diabetes, blood pressure, asthma reviews and irregular heart function.
• The practice had identified 1.4% of the practice list as being carers. The GP care advisor held regular clinics at the practice and was able to signpost carers to support in relation to benefits, grants and other means of support and assessment.
• There were measures in place which sought to address the needs of the practice population, including clinics held at the practice and online services, although there were continued issues with delayed appointments and waiting times.
• There was no effective, overarching strategy or oversight to ensure that the care provided was safe, effective, responsive and well-led.
• Governance systems were not effective and required improvement. There was not a comprehensive overview of performance and staff were unsure where to find required information, such as admission avoidance registers.
• There were some positive examples of the practice acting on patient feedback, such as initiating a monthly meeting with a local care home when issues were identified; however, effective responses when general concerns were raised was inconsistent.

• The practice was identified as the only practice in Essex to have been recognised as a dementia friendly practice. This meant that the practice was awarded for being accessible for patients with dementia, which included the use of visual aids to support patients to navigate around the practice.

Action the provider MUST take to improve:

• Implement processes to monitor the refrigerators storing vaccines to ensure that recommended temperatures are maintained and risks to patients are mitigated.
• Follow recognised processes in relation to the management of controlled drugs and implement effective systems to ensure that staff are following them.
• Monitor patients prescribed high risk medicines.
• Implement effective systems to ensure that prescriptions for repeat medicines are signed by the doctor before being dispensed.
• Monitor prescription stationery to ensure this handled in line with national guidance.
• Mitigate risks to patients by ensuring patients’ records include a full list of medicines that they are taking.
• Implement effective processes to ensure that all medicines in use have not expired and are suitable for use.
• Update policies and procedures to reflect leads, contacts and current arrangements and ensure these are easily located.
• Mitigate the risks associated with the area where medicines are stored at the Stanway location by completing a risk assessment to ensure these are secured appropriately.
• Ensure recruitment processes are followed to ensure that staff are suitable and trained for the role for which they are employed.
• Mitigate the risks associated with staff acting as chaperones by ensuring relevant staff receive a disclosure and barring service check or a risk assessment is in place as to why one was not necessary.
• Improve the leadership and governance at the practice so that risks to patients are identified and mitigated, the quality of the services provided are monitored and assessed and health outcomes for patients are improved.
• Ensure atropine is available in the event of a medical emergency or assess the risk of not doing so.

Action the provider SHOULD take to improve:

• In the dispensary, ensure there is a clear process in place to monitor, record and review near misses in relation to medicine errors.
• Record detailed meeting minutes.
• Take steps to improve access and respond to the issues raised in the National GP Patient Survey.
• Ensure that the learning from significant events is cascaded to all relevant staff to reduce the risk of reoccurrence.

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 found the Stanway Surgery reception staff courteous and welcoming to people during our inspection on 2 September 2013.

In the reception area and waiting room we saw a selection of information displayed for the benefit of the patients. These included notices about the surgery services, leaflets on health promotion, safeguarding and other support services.

We received comments from people about the surgery on the day of inspection. One person told us: "The doctor thoroughly explained my treatment options, and they even remind you when you’ve got an appointment."

One of the doctors we spoke with told us they involved people in their care. They told us: "We try to let people see their doctor of choice, and involve them in decisions for diagnostic and treatment options."

The evidence we saw assured us the surgery protected people against the risks associated with medicines.

The staff members told us they were supported in their work roles through training and development.

We found the surgery monitored and assessed the quality of their service to identify risks and improve quality.