Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Park Road Surgery over two days, 21 January 2016 and 15 February 2016 and rated the practice as requires improvement for providing effective services, good for providing safe, caring, responsive and well led services with an overall rating of good.

We carried out an announced follow-up inspection at Park Road Surgery on 16 May 2017 to check that the practice had taken action to bring about improvements. At that inspection we found that working relationships between partners had become strained and dysfunctional and this had had an impact on the management capacity at the service. Following this inspection, the practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall. We issued requirement notices in respect of breaches of regulations and the practice was placed into Special Measures for a period of six months. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The reports from the inspection of January and February 2016 and the inspection of May 2017 can be found by selecting the ‘Reports’ link for Park Road Surgery on our website at www.cqc.org.uk/location/1-571411376

This inspection was an announced comprehensive inspection on 13 December 2017 and was undertaken following the period of special measures 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 on 16 May 2017. 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 requires improvement.

Our key findings at the inspection on 13 December 2017 were as follows:

• When we inspected in May 2017, we found that the practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements. At this inspection we found that the partnership arrangements had changed and a new partnership management team had brought stability and leadership to the practice. Governance arrangements had been reviewed and protocols had been put in place to ensure that management had effective oversight of practice performance.
• At our inspection in May 2017, we found that patients were at risk of harm because the practice did not have an effective system in place to ensure all clinicians, a significant number of whom were locum staff, were kept up to date with national guidance and guidelines. At this inspection, we saw that the practice had significantly reduced the use of locum staff and had established a system to ensure that guidelines, updates and patient safety alerts were distributed to all clinical staff and were discussed at clinical meetings.
• The practice had reviewed arrangements in place to safeguard children and vulnerable adults from abuse to ensure that all staff were clear about their own roles and that of the safeguarding lead. All staff who carried out chaperoning duties had now received appropriate training.
• The practice was put a system in place to ensure that prescriptions awaiting collection were monitored regularly and GPs made aware when prescriptions remained uncollected for more than four weeks. Prescriptions for high risk medicines or those for patients with mental health or other serious conditions were monitored more closely and GPs made aware if a prescription had not been collected within one week.
• When we inspected in May 2017, we found that although staff were clear about reporting incidents, near misses and concerns, there was no evidence of learning and communication with staff. At this inspection we found that the practice had established regular practice meetings and used a standard agenda which included serious incidents and significant events as a standing item and used this as an opportunity to discuss incidents and share learning points and suggestions for improvement.
• The practice had consulted best practice guidelines around emergency medicines for a GP practice and could demonstrate that an appropriate schedule of medicines had been maintained since the previous inspection and there was a process in place to ensure these were regularly reviewed to ensure they were available and fit for purpose when required.
• When we inspected in May 2017, we found that clinical letters received electronically into the patient document management systems were not always reviewed or acted upon in a timely way. At this inspection, we saw the new practice management team had worked with an external adviser to review the document management process and had identified areas where the practice had not been using the practice computer system to its full potential. Measures had been put in place to ensure that patient related correspondence was reviewed daily.
• At our inspection in May 2017, data showed patient outcomes were low compared to the national average in key clinical areas such as Diabetes. At this inspection, we noted the new practice management team had prioritised improving patient outcomes as a key area for development and had reduced the use of locum GPs in order to improve continuity of care and an effective patient recall system had been put in place. Although the most recently published data showed that patient outcomes for some clinical areas were still lower than the national average, unvalidated year to date performance data for 2017/2018 indicated that practice performance had increased significantly in each of these areas and the practice was in line to improve performance further in the remaining quarter of the current measuring period.
• The practice had started to develop a quality improvement programme and had recently completed two audit cycles.
• Patients were positive about their interactions with staff and said they were treated with compassion, dignity and respect and the practice had put in place an effective system for proactively identifying patients who were carers to offer them additional support.
• Results from the national GP survey showed that patient satisfaction around access to the service was lower than local and national averages. In response to this, the practice had reduced the use of locums by 80% and had increased the number of staff employed in the reception team and had

The areas where the provider should make improvement are:

• Continue to assess and monitor the performance of the practice by following through with plans to reduce high exception reporting and an action plan to continue to improve outcomes for patients.
• Continue to monitor patient satisfaction and consider taking further actions to bring about improvements so that practice performance is in line with national survey results.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the 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 Park Road Surgery over two days, 21 January 2016 and 15 February 2016 and rated the practice as requires improvement for providing effective services, good for providing safe, caring, responsive and well led services and an overall rating of good. The full comprehensive report on the 2016 inspection can be found by selecting the ‘all reports’ link for Park Road Surgery on our website at www.cqc.org.uk.

This inspection was a follow up announced comprehensive inspection carried out on 16 May 2017 to check that the practice had taken action to bring about improvements. This report covers our findings in relation to those requirements.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice did not have an effective system in place to ensure all clinicians were kept up to date with national guidance and guidelines.
• The practice had arrangements in place to safeguard children and vulnerable adults from abuse but there were gaps in these arrangements, for instance it was unclear who was carrying out the role of the safeguarding lead and some staff who carried out chaperoning duties had not received appropriate training.
• There was no system in place to monitor uncollected prescriptions.
• Although staff were clear about reporting incidents, near misses and concerns, there was no evidence of learning and communication with staff.
• The practice had only a limited range emergency medicines available, one of which had passed its expiry date. This meant it would not have been able to respond adequately to many medical emergencies. However, the practice had consulted best practice guidelines around emergency medicines and had arranged a delivery of a suitable range on the day of the inspection.
• Clinical letters received electronically into the patient document management systems were not always reviewed or acted upon in a timely way. For instance, we identified approximately 370 incomplete correspondence records dating back to April 2017 in the practice work flow system. These were reviewed and completed on the day of the inspection and arrangements put in place to prevent a repeat of the incident.
• Data showed patient outcomes were low compared to the national average in key clinical areas such as Diabetes.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• Patients were positive about their interactions with staff and said they were treated with compassion, dignity and respect. However, the practice did not have an effective system for proactively identifying patients who were carers to offer them additional support.
• Results from the national GP survey showed that patient satisfaction around access to the service was lower than local and national averages.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• The provider must ensure care and treatment is provided in a safe way to patients by introducing systems to ensure all clinicians are kept up to date with patient safety alerts, national guidance and guidelines and put measures in place to monitor that these are being followed; ensuring that staff are aware of who is carrying out the role of safeguarding lead and ensuring that that all staff carrying out the role of chaperone receive suitable training.
• The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care by introducing reliable processes for acting on and monitoring significant events, incidents and near misses;

putting a system in place to ensure repeat prescriptions are managed safely, ensuring that systems and processes such as clinical audits are in place to assess, monitor and improve the quality and safety of the service; ensuring management arrangements for overseeing performance in the practice are effective and using feedback from the national GP Patient survey for the purposes of continually evaluating and improving the quality of the service provision.

The areas where the provider should make improvement are:

• Continue to monitor supplies of emergency medicines and ensure these reflect the regulated activities undertaken at the practice and ensure that a paediatric mask is provided for use with the oxygen supply.
• Ensure recruitment for locum clinical staff is safe and these staff have access to clinical updates and best practice guidelines and consider arrangements to audit patient records to ensure guidelines are followed.
• The provider should implement a failsafe process to ensure that results for all specimens taken for cervical cytology have been received and to monitor the rate of inadequate specimens sent for analysis.
• The practice should review the current arrangements for ensuring urgent referrals have been received and appointments made. Review business continuity arrangements to ensure that copies of the continuity plan is available to staff and that at least one copy is held off-site.

• The practice should review the current uptake for cancer screening programmes among eligible patients with a view to improvement.

• Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.

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

During this inspection we spoke with four patients, two GPs, the practice manager, deputy practice manager and the head receptionist. Patients we spoke with informed us that they were satisfied with the care and treatment provided. They indicated that they had been well treated by staff. One patient said, “I am happy with the practice. My family have been coming here for years. I get the right treatment from the doctors”. Another patient told us, "The GP is fine. I have been treated with respect and dignity. They close the door when I am seeing them”.

The records of three patients contained details of assessments and their past medical history. Treatment and care provided were documented. Patients informed us that when necessary, their consent had been obtained. Reviews of treatment and care provided took place and there was a system for following up patients who had missed important monitoring appointments.

We saw documented evidence which indicated that staff had updated their professional knowledge and skills. Staff records we examined contained documented evidence of all essential pre-employment checks that should have been carried out on staff.

The practice had arrangements for safeguarding people from abuse. Staff were aware of action to take when responding to allegations or incidents of abuse. Safeguarding policies and procedures were in place.

The practice had a system of internal audits and checks to monitor the quality of service that patients received. A recent satisfaction survey of patients indicated that they were satisfied with the services provided. The only complaint recorded in the past twelve months had been promptly responded to.

The practice manager indicated that the practice was assisted in improving the quality of care by an organisation which provided support to the local group of GPs. Assistance was provided to enable GPs to share staff resources, management and clinical expertise and training opportunities.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Park Road Surgery during visits on 27 January 2016 and 15 February 2016. Overall the practice is 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 an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Data showed patient outcomes for some indicators were low compared to the national average. However, we saw evidence that the practice had put some measures in place to drive improvements to patient outcomes.

• 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. 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Ensure that all portable electrical appliances are tested for safety.
• Review fire safety arrangements to include the planned fire risk assessment and fire evacuation drill.
• Continue to review and improve outcomes for patients with long term conditions.
• Review the process for monitoring uncollected prescriptions.
• Ensure the practice actively identifies and supports patients who are also carers.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice