Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of Dr Roy Alexander also known as Marshalls Road Surgery on 17 July 2018. This inspection was undertaken to follow up on warning notices we issued to the provider in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance.

The practice received an overall rating of inadequate at our inspection on 29 January 2018 and this will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full comprehensive report from the January 2018 inspection can be found by selecting the ‘all reports’ link for Dr Roy Alexander on our website at .

Our key findings were as follows:

• The practice had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
• Systems in place to safeguard children and vulnerable adults had been improved.
• Evidence of pre-employment checks was now available and all staff had received a disclosure and barring (DBS) check.
• Staffing levels had been reviewed and additional staff had been recruited to support the practice manager.
• Measures had been put in place to ensure the safe and appropriate use of medicines.
• A fire risk assessment had been completed by a qualified person and appropriate actions had been taken in response to the assessment.
• Staff now understood their duty to raise concerns and report incidents and near misses.
• Processes had been implemented to ensure the management of safety alerts received.
• Governance arrangements in the practice had been strengthened. Staff meetings were formalised and policies and procedures had been reviewed and now covered all pertinent areas including business continuity, safeguarding and infection control.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating 01/2018 – Inadequate)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Roy Alexander also known as Marshalls Road Surgery on 29 January 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. Warning notices were served in relation to breaches identified under Regulation 12 Safe care and treatment and Regulation 17 Good governance. We completed an announced focussed inspection on 17 July 2018 to check on the areas identified in the warning notices

and found that sufficient improvements had been made regarding these.

The full comprehensive report on the January 2018 inspection and the focussed report for the July 2018 inspection can be found by selecting the ‘all reports’ link for Dr Roy Alexander on our website at .

This announced comprehensive inspection on 3 October 2018 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

At this inspection we found:

• The practice had clear 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. Staff understood their duty to raise concerns and report incidents and near misses.
• Governance arrangements in the practice had been strengthened. Staff meetings were formalised and policies and procedures had been reviewed and now covered all pertinent areas including business continuity, safeguarding and infection control.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• All staff were involved in making improvements to the practice. The practice had reviewed its staffing needs and additional staff had been recruited to support the practice manager.
• An infection control audit had been completed. However, the practice had not completed the areas that required attention and did not have an action plan in place to address them.
• Complaints were managed according to recommended guidance. However, the date was not recorded on the letters sent to the complainant.

The areas where the provider should make improvements are:

• Complete the areas that were identified as requiring attention in the infection control audit.
• Review the complaints procedure particularly in relation to the dating of communications to demonstrate the recommended timeframes for responding to complaints are met.
• Develop ways to engage with patients and gather feedback in the absence of a patient participation group.

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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Roy Alexander’s practice on 21 June 2016. Overall the practice is rated as requires improvement.

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, with the exception of those relating to recruitment checks.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment, but there were gaps in training for non-clinical staff.
• 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 but complaint forms and information about how to complain was kept behind the reception desk and would be given if requested. There had been no complaints received from patients to review.
• Patients said they found it easy to make an appointment with a GP and urgent appointments were available the same day.
• The practice had adequate facilities and was equipped to treat patients and meet their needs.
• The GP led the practice and staff felt supported. The practice responded to patients verbal comments but did not have formal evidence of patient feedback with the exception of the national survey.
• The practice had a number of policies and procedures to govern activity, but many were overdue a review.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• The practice must ensure that all policies and procedures are reviewed, including standard operating procedures in the dispensary, introduce a system to regularly update them and make them all accessible to staff.
• Ensure recruitment arrangements include all necessary employment checks for all staff and are recorded accurately.
• Introduce a structured induction programme for new staff to include essential training.
• Ensure all staff receive essential training such as safeguarding and chaperoning.
• Carry out a risk assessment for all potential hazards, such as window blind cords.
• Introduce a system to record and monitor hand written prescriptions.
• Ensure the business continuity plan is updated to include details of how the practice would function in the event of the building becoming unusable.

The areas where the provider should make improvement are:

• Ensure consent forms are scanned and included in the patient’s record.
• Carry out a fire drill and ensure they are carried out at regular intervals.
• Ensure the complaints procedure is available for patients to view in the waiting area.
• Ensure all patients’ dissatisfaction is directed via the complaints procedure.
• Continue to try to establish a patient participation group.

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 of Dr Roy Alexander in June 2016. . The overall rating for the practice was requires improvement. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Dr Roy Alexander on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 29 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Inadequate.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Good

Are services well-led? – Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) – Inadequate

At this inspection we found:

• Although systems were in place to enable staff to report and record significant events, during our inspection the practice could not demonstrate that all significant events were reported or recorded.
• Patients were potentially at risk of harm because systems were not operated effectively to keep patients safe including those for dealing with safety alerts.
• A fire risk assessment had been undertaken in 2016; however parts of the assessment had not been completed.
• Prescription stationery was not stored securely and was not tracked in line with guidance.
• The practice had regular meetings with the health visitor to enable joint working, discussion and review of children at risk. However, the practice could not provide a copy of a child safeguarding policy and non-clinical staff had not received safeguarding training.
• Systems to ensure the security of controlled drugs were not being operated effectively. Arrangements to respond to emergencies needed to be reviewed and improved.
• There were limited processes in place for disseminating guidance from the National Institute of Health and Care Excellence (NICE) and local guidelines. Clinical meetings were not held within the practice.
• There was limited evidence to demonstrate quality improvement. Although some audits had been undertaken; there had been no two-cycle audits completed where improvements had been made and the monitored.
• Data from the Quality and Outcomes Framework highlighted areas where improvements were required.
• Information about services and how to complain was available and easy to understand.
• Policies and processes needed to be reviewed to ensure these were fit for purpose and being operated effectively.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Evidence provided during our inspection indicated that service improvement was not a priority amongst leaders. For example there was no evidence of action being taken to address below average satisfaction scores for consultations with GPs.

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

• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

• Review and improve arrangements for the identification of carers in order to offer them with support where needed
• Review the practice website to ensure content is up to date

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