We carried out an announced comprehensive inspection of Shrewsbury Road Surgery on 10 January 2019 as part of our inspection programme.

At the last inspection on 9 November 2017 we rated the practice as requires improvement overall, and as requires improvement for providing caring and well-led services because:

• The practice had not taken effective action to understand or improve low GP patient survey scores.
• Arrangements to ensure the practice was able to assess and improve its own performance needed embedding, such as understanding and responding to below average patient feedback or performance data.
• Business continuity arrangements had not been clarified or formalised to cover staff absence.
• The system to ensure the safety of electrical equipment was not effective.

At this inspection, we found the provider had satisfactorily addressed these areas.

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 and good for all population groups.

We found that:

• The practice provided care in a way which kept patients safe and protected them from avoidable harm.
• The practice reviewed and monitored the effectiveness and appropriateness of the care and treatment it provided.
• Care and treatment was delivered according to current evidence based guidance and standards.
• Patient feedback about the practice was positive and the practice acted upon feedback.
• The practice had an active patient participation group.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• There was a clear leadership structure and staff told us they felt able to raise concerns and were confident these would be addressed.
• The way the practice was led and managed promoted the delivery of high-quality and person-centre care.

There was one area where the provider could make improvements and should:

• Review staff understanding of and compliance with hand hygiene practices.

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

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

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection 19 December 2016 – Inadequate)

At our inspection on 9 November 2017 we found:

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? - Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced comprehensive inspection at Shrewsbury Road Surgery on 9 November 2017. We inspected the provider as part of our inspection programme, in response to concerns, to follow up on breaches of regulations.

This inspection was a follow up to earlier inspections carried out on 22 March 2016 and 19 December 2016. Following the inspection on 22 March 2016 the practice was rated inadequate in providing safe services, requires improvement in providing effective, responsive and well-led services, and good in providing caring services. It was rated requires improvement overall and there were breaches of Regulation 12 - Safe care and treatment and Regulation 17 - Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the inspection 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.

We carried an inspection on 19 December 2016 to follow up on the 22 March 2016 inspection and consider whether sufficient improvements had been made for provider to meet legal requirements and associated regulations. The practice was rated inadequate in providing responsive and well-led services, requires improvement in providing safe and caring services, good in providing effective services, inadequate overall and was placed in special measures. The provider had made some improvements; however there were new breaches of Regulation 16 - Receiving and acting on complaints and continued breaches of Regulation 17 - Good governance. After the inspection the provider submitted an action plan stating how it would make further improvements and when the practice would be meeting the legal requirements and regulations.

This inspection on 9 November 2017 was an announced comprehensive inspection undertaken following the period of special measures to follow up and consider whether sufficient improvements had been made for provider to meet legal requirements and associated regulations.

Overall the practice is now rated as requires improvement.

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.
• The practice routinely reviewed the effectiveness of the care it provided and ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had improved patient telephone and appointment access but patient survey feedback such as practice nurses care was not understood or followed up effectively.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Evidence generally showed staff involved and treated patients with compassion, kindness, dignity and respect.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• Governance systems had improved but further improvement or embedding was needed in some areas needed such as business continuity plans and quality improvement.

The areas where the provider must make improvements are:

• Establish and embed effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

An area where the practice should make improvements is:

• Seek to further understand and improve performance data for cervical screening.

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 Shrewsbury Road Surgery on 22 March 2016 and rated the practice as inadequate for safety, requires improvement for effectiveness, responsive and well led, good for caring, and an overall rating of requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Shrewsbury Road Surgery on our website at www.cqc.org.uk.

This inspection was a follow up announced comprehensive inspection carried out on 19 December 2016 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 22 March 2016. This report covers our findings in relation to those requirements

Overall the practice is rated as inadequate. Our key findings across all the areas we inspected were as follows:

• The practice had not demonstrated sufficient progress or impact to improve patient’s telephone access and systems for complaints management were not always effective.
• The practice appointment system involved extended waiting times and a lack of clarity for patients and there was no method to check its effectiveness.
• Systems to ensure vulnerable or at risk patients were followed up appropriately following discharge from hospital or attendance at accident and emergency were ineffective.
• Arrangements for maintaining patient’s confidentiality had gaps and were ineffective.
• Risks to patients were generally assessed and well managed but there were weaknesses in arrangements for monitoring prescriptions, emergency medicines and staff recruitment and induction.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance and had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment, with the exception of fire safety training.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The provider was aware of and complied with the requirements of the duty of candour.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider must make improvements are:

• Ensure effective arrangements for staff recruitment checks and induction, fire safety training and emergency medicines.
• Use feedback from relevant persons such as the national GP Patient survey for the purposes of continually evaluating and improving the quality of the service provision.
• Implement formal governance arrangements such as systems for assessing and monitoring risks.
• Establish an effective and accessible system for managing complaints.

The areas where the provider should make improvements are:

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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 Shrewsbury Road Surgery on 22 March 2016. Overall the practice is rated as requires improvement.

• The practice had good facilities and was equipped to treat patients and meet their needs.
• 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.
• There was a leadership structure and staff felt supported by management.
• The practice had proactively sought feedback from patients which it acted on, and had an active patient participation group.

• Staff generally had the skills, knowledge and experience to deliver effective care and treatment.

However, we found a number of issues of concern –

• Patients were at risk of harm because an unlicensed staff member was responsible for actioning patients’ laboratory test results.
• Staff generally assessed patients’ needs and delivered care in line with current evidence based guidance. But where patients had care plans in place, the plans were not always appropriately assessed or properly completed.
• There was a system for reporting and recording significant events. But reviews and investigations did not result in actions to improve processes to prevent the same thing happening again.
• The provider did not have a backup for the paper folder of practice specific policies and there was varying GP partner knowledge, understanding and implementation of some policies that were critical to the quality and safety of patients care.

• The practice did not maintain a child protection list and arrangements for safeguarding children were not robust.
• Some risks to patients were assessed and well managed, and others such as infection control and Legionella were not.
• Systems to ensure vulnerable or at risk patients were followed up appropriately following discharge from hospital or attendance at accident and emergency were not robust.
• Appointment systems predominantly ran on a first come first served ticketing system. Patients did not always receive timely care when they needed or find it easy to make an appointment with a named GP.
• Telephone access arrangements were complicated and not accurately reflected on the practice leaflet.

The areas where the provider must make improvements are:

• Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely in accordance with their role.
• Manage safety incidents robustly and ensure lessons learned are used to make improvements to prevent recurrence.
• Implement effective child safeguarding arrangements.

• Make appropriate arrangements for patients care plans.
• Make appropriate arrangements for infection prevention and control.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure there is leadership knowledge, skill and capacity to deliver all improvements.
• Ensure Patient Specific Directives (PSDs) to enable Health Care Assistants to administer vaccinations after specific training and when a doctor or nurse are on the premises are signed and authorised appropriately by a GP before vaccines are administered.

In addition the provider should:

• Provide emergency use oxygen masks for children.
• Ensure recruitment arrangements include all necessary employment checks for all staff and include safeguarding during induction for all staff.
• Implement a system to ensure vulnerable or at risk patients are followed up appropriately following discharge from hospital or attendance at accident and emergency.
• Consider reviewing arrangements for staff members’ access to policies and procedures and information kept on single paper copy documents.
• Review the system for patients’ appointments and duration child immunisations and travel immunisations appointments.
• Make clear and suitable arrangements for patients to contact the practice by telephone and ensure the patients’ information leaflet is accurate.
• Ensure actions identified in the Legionella risk assessment are carried out.
• Review the prescribing policy.
• Ensure all staff are included in meetings and receive supervision as appropriate to their role.
• Ensure all staff receive up to date training in such subjects as fire safety, safeguarding, chaperoning and the Mental Capacity Act 2005 in accordance with their role, and keep a documented record of such training.
• Make appropriate arrangements for patients chaperoning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

There was an appropriate consent protocol in place which was followed by the doctors and practice nurse. Patients we spoke with confirmed that their medical needs had been assessed and they had agreed to the treatment they received.

Most patients felt they received good care and treatment. We were told that non-clinical staff were “friendly and helpful” and the doctors took “time to explain so you understand the symptoms and treatment.” Everyone we spoke with considered staff were competent to carry out their work.

There was an appropriate policy and procedure in place for the protection of vulnerable adults and children. However, staff had received training in adult protection which meant their knowledge and understanding was limited.

Although the practice nurse was able to discuss clinical concerns with the practice doctors, they were not being included in any formal practice meetings. This meant they were not being given the same opportunity for support as all other staff.

We saw that the practice had an appropriate complaints policy. There was evidence that this was followed and learning from complaints took place.