We carried out an announced comprehensive inspection at Nexus Health Group on the following dates:

Provider inspection at Princess Street Group Practice – 1 November 2018

Manor Place Surgery – 7 November 2018

Princess Street Group Practice – 14 November 2018

Surrey Docks Health Centre – 15 November 2018

Aylesbury Medical Centre – 20 November 2018

The Dun Cow Surgery – 21 November 2018

Commercial way Surgery – 22 November 2018

Decima Street Surgery & Artesian Health Centre - November 2018

We rated the practice inadequate and they were placed into special measures. Because of the concerns found at the inspection, we served the provider with two warning notices for breaches of regulation 12 and 17 of the Health and Social Care Act 2008 (2014 Regulations).

This was an announced focused inspection on 13 February 2019. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements as detailed in the warning notices issued on 12 November 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.

This inspection was an unrated inspection to follow up on warning notices and the rating remains unchanged.

At this inspection we found:

• The provider had a backlog of patients who required a review of their medication, including some patients on high risk medicines. The provider had designed systems which aimed to ensure that patients had medication reviews in line with guidance going forward. However, the system did not require clinical intervention for approximately two to three months after the missed review and did not outline how the practice would manage patients on high risk medicines who repeatedly failed to attend for reviews.
• Systems had been developed to introduce effective oversight of clinical tasks, correspondence and results. Safety monitoring had been introduced for systems used to enable non- clinical staff to review and workflow clinical documentation to GPs.
• The provider’s two week wait referral systems had been improved to ensure that they were failsafe.
• Risk management systems related to legionella, fire and the oversight of emergency equipment were now in place.
• Prescriptions were secure and their use monitored. The provider had implemented systems to ensure periodic reviews of uncollected prescriptions.
• The provider had developed systems to check locum staff mandatory training was in place although we saw one instance where a long-term locum GP had not completed basic life support training in the last 12 months.
• Both clinical and managerial support had been provided to Manor Place Surgery.
• The provider had worked to improve the systems around the identification and prioritisation of risk.

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

• Ensure that care and treatment is provided in a safe way.
• 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 systems around locum staff training.

A further inspection will be undertaken to ensure that the provider has complied with the conditions as set out above.

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 announced comprehensive inspection at Princess Street Group Practice on 22 April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well led services. The practice was good for providing services for the six population groups we report on: older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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 with a named GP and that there was continuity of care, with 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.

We saw a number of areas of outstanding practice:

• The practice was particularly effective in supporting patients with long term conditions. Data from the Southwark population health services showed that the practice had achieved double its target for the 2014 /15 year in collaborative care planning for patients with certain long term conditions. The practice was a high QOF achiever, their performance for clinical domain indicator groups was better than the local and national averages for all diseases reported. The practice performance was 100% for all but two groups.
• The practice is near Southbank University and actively engaged with students at Fresher’s week with registration opportunities and sexual health screening information. They also worked closely with the health advisors based at the university.

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

The provider should

• Ensure infection prevention and control policies and procedures are kept under review and up to date.
• Ensure portable appliance testing (PAT) and fire safety checks are completed in line with the practice’s policy

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Nexus Health Group is a provider registered with CQC. The provider has eight sites with one sites used at the CQC registered location. The sites were previously independent GP practices which merged to become Nexus Health Group in 2016. The individual sites have retained the names from the historic partnerships.

We carried out an inspection at the head office site, Princess Street Group Practice, on 1 November 2018 as part of our GP provider at scale pilot. This was to assess the centralised functions within Nexus Health Group. The individual sites were then to be individually inspected as part of our regularly scheduled inspection programme.

Due to concerns identified at the provider level inspection on 1 November 2018 we issued a letter of intent (informing the provider of our intention to take enforcement action) and allowed the provider to submit a response. The provider submitted an action plan in response to the letter of intent. We undertook an unannounced inspection of Manor Place Surgery on 7 November 2018 on the basis of concerns raised at the provider level inspection and information submitted by the provider before and after the inspection on 1 November 2018. After the inspection on 7 November 2018 we issued warning notices for breaches of regulation 12 (Safe Care and Treatment) and 17 (Good Governance) of the The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Details of the concerns raised and enforcement action taken can be found at the end of this report. We then proceeded to inspect the remaining sites as follows:

Princess Street Group Practice – 14 November 2018

Surrey Docks Health Centre – 15 November 2018

Aylesbury Medical Centre – 20 November 2018

The Dun Cow Surgery – 21 November 2018

Commercial way Surgery – 22 November 2018

Decima Street Surgery & Artesian Health Centre - 28 November 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 inadequate overall and requires improvement for all population groups.

We rated the practice as inadequate for providing safe services because:

• The practice did not have appropriate systems in place for the safe management of medicines at all sites.
• Staff did not all have safeguarding, fire and infection control training.

• Necessary recruitment information had not been retained for all staff and the practice had not undertaken DBS checks for all staff who required them.

• Not all staff had evidence of their immunisation status on file.
• There were 1023 results dating back to 2 July 2018 which had either not been filed or not been viewed and filed. Four hundred and forty-two of these results were marked as being abnormal. Of the sample of 30 outstanding results we reviewed we found that five of these results had not had appropriate action taken. There were 4187 outstanding clinical tasks dating back to 13 February 2017 which had not been actioned. Of 40 unactioned tasks we reviewed four highlighted concerns related to the quality of clinical care being provided by the service. The provider put an action plan in place to review the outstanding tasks and results and put systems in place to prevent this from reoccurring.
• There was no global oversight of a separate electronic system for incoming results and correspondence.

• Necessary tasks were not being completed at some sites due to a multitude of reasons including staffing shortages and lack of effective governance

• Some sites did not have a system in place to monitor non-medicine safety alerts.
• We found some expired medical emergency equipment at some sites and the systems for checking equipment and vaccines was not consistent across all sites.
• Risks associated with the premises were not adequately mitigated at some sites including those risks associated with legionella and fire.
• The practice did learn and make improvements when things went wrong at site level but there was little evidence of cross site learning from significant events.

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

• There was a lack of effective centralised oversight and governance in respect of key areas of the organisation including the management of test result and other clinical correspondence.
• Leaders could not show that they had the capacity and skills to deliver safe and effective care as at this stage of the merger process they did not have adequate oversight of risks within the organisation and lines of responsibility were not always clear.
• While the provider had a clear vision, and was in the process of developing a strategy to implement this; transitional arrangements put in place during the development of the merger were not sufficient to ensure that high quality care was being consistently provided across all sites.
• The practice culture aimed to support the delivery of high quality sustainable care. However, deficiencies in governance limited the practice’s ability to achieve this aim.
• The practice did not have clear and effective processes for managing risks, issues and performance. For example, in relation to risks associated with legionella, fire safety risks and medical emergencies.
• The provider had tried to institute a Nexus-wide patient participation group across all sites but this was not operating effectively.
• The practice did not always act on information appropriately. For example, the practice had previously identified the concerns related to clinical correspondence but had failed to put adequate systems in place to address this issue prior to our inspection. The provider took action following our provider level inspection to put systems in place to address this concern.
• We saw evidence of systems and processes for learning, continuous improvement and innovation.

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

• Due to concerns related to the lack of oversight of clinical correspondence we could not be assured that patients were receiving consistently high quality and effective care.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles as not all staff had received an appraisal or completed mandatory training.

However

• There was evidence that outcomes of care and treatment were being monitored.
• The practice demonstrated that staff obtained consent to care and treatment.
• Performance data was comparable to local and national averages in most areas with the exception of cervical screening and uptake of childhood immunisations.

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

• Although the practice organised and delivered services to meet patients’ needs. Patient feedback from the national GP patient survey indicated that patients could not always access care and treatment in a timely way. Although the practice was taking steps to improve access; action had not been implemented. The practice had not undertaken their internal feedback exercise to see if access had improved.

These areas in effective and responsive services affected all population groups so we rated all population groups as requires improvement

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• There were a lack of formalised systems and processes in place to support carers and patients who had experienced bereavement at some sites.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• 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). Note: Warning notices were issued to the provider following the inspection undertaken on 1 and 7 November. This was to ensure that the provider was aware of our concerns and that action was taken quickly to address these concerns and mitigate risks to patients. Requirement notices were issued for the additional concerns which related to breaches identified at the end of the inspection cycle. The level of risk stemming from these concerns was not deemed to be sufficient to require additional enforcement action.

The areas where the provider should make improvements are:

• Continue with work to improve the uptake of childhood immunisations and cervical screening rates.
• Review staffing levels across the organisation to ensure that there is sufficient capacity to complete all necessary tasks.
• Review systems for sharing learning from significant events across the organisation.
• Review systems in place to support patients with caring responsibilities and those who have suffered bereavement.
• Review systems related to the security of patient records.
• Continue with plans to address patient satisfaction around access and review the impact of these actions once implemented.
• Review and improve the systems in place to engage with patients and obtain feedback.
• Consider ways to provide information in different languages and in alternative formats for patients with learning disabilities.

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.

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