We carried out an announced comprehensive inspection at the surgical unit at Southgates and The Woottons Surgeries, previously known as Dr H I Lazarus and partners, on 03 and 10 August 2017. This inspection was unrated. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Southgates and The Woottons Surgeries on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 June 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 August 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. The surgical unit remains unrated. Our key findings were as follows:

• The service applied inclusion and exclusion criteria to help staff assess patients’ suitability for the service. Following an incident relating to an inappropriate referral we saw that the provider had reviewed and amended their surgery inclusion criteria.

• All training the practice deemed mandatory was up to date with the exception of basic life support for one surgeon, which had already been arranged prior to our inspection to be undertaken in the week following our inspection.

• Systems were in place, including appraisals for clinical staff, to support senior staff to be assured of the ongoing competency and clinical skills of the surgeons working in the service.

• Bank nursing staff had received appraisals since our last inspection. As a result of the appraisals staff had been provided with further learning and development opportunities.

• Regular surgery team meetings including all staff had been introduced to provide better oversight of the service. The surgery manager described the meetings as a good forum to discuss any issues which may have arisen from the team, referral rates, waiting list times, maintenance, audits and budget matters.

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 Lazarus and Partners on 3 January 2017. The overall rating for the practice was good but with breaches identified in regulation 12. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Lazarus and Partners on our website at www.cqc.org.uk.

This inspection was carried out 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 3 January 2017. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

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

• The practice had recently taken over responsibility for another practice within the area; this second practice, The Woottons is now a branch site of Dr Lazarus and Partners.

• To ensure that patient’s records and care was integrated, in February 2017, the main practice changed its computer operating system to the same one used at the branch site.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• The systems and processes in place to ensure and record that all staff were safely employed had been improved.

• Systems and processes had been implemented to record the immunisation status of staff appropriate to their role.

• The practice had implemented systems and processes to identify and mitigate risks relating to fire safety and legionella.

• The practice training log had been significantly improved; accurate records were kept and there was effective oversight to ensure staff received the training appropriate to their role and responsibilities.

• The practice system to ensure all prescription stationary was safely monitored needed to be improved.

• Practice 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.
• 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 ensured that information about how to complain was easily available.
• 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.

We saw an area of outstanding practice;

• The practice had over 5000 patients who did not speak English as a first language. The practice had identified that Russian and Lithuanian were the two most common languages spoken, and in addition to the translation services available they had employed three staff members who were able to translate these languages for patients ensuring they had easy access to healthcare.

There was one area where the provider should make improvements:

Review and improve the process to ensure blank prescriptions are tracked and recorded.

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 H I Lazarus and Partners on 3 January 2017. The practice is also a surgical centre and registered for acute services; we did not inspect the surgical unit as part of this inspection. Overall the practice is rated as good.

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

• The practice had recently taken over responsibility for another practice within the area; this second practice held a separate contract for providing medical services and was not part of this inspection. A new management team had recently been formed to ensure consistent and sustainable management over both practices.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The practice used a range of assessments to manage the risks to patients; however management oversight of these needed to be improved.
• Practice 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.
• Patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.
• Information about how to complain was not easily available. However where patients did complain, improvements were made to the quality of care as a result.
• 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.

We saw areas of outstanding practice;

• The practice enhanced the skill mix available to meet the patients’ needs. For example, they employed two specialist nurses (matrons) to ensure vulnerable housebound patients were well supported and received holistic care. Both nurses held a prescribing qualification, which enabled them to ensure that patients received timely, appropriate care. These nurses also visited the local care homes to support the GPs and care staff to ensure patients are cared for in the place of their choice. Furthermore, the practice had over 5000 patients who did not speak English as a first language. The practice had identified that Russian and Lithuanian were the two most common languages spoken, and in addition to the translation services available they had employed three staff members who were able to translate these languages for patients ensuring they had easy access to healthcare.

• One GP partner had additional qualifications in mental health and was previously section 12 approved (some decisions under the Mental Health Act, such as deciding on your medication or giving you permission to leave the ward or hospital, can only be taken by approved clinicians). The practice told us that this enabled them to manage patients who may be experiencing poor mental health within the practice setting, in particular the patients who did not speak English as a first language. The GP shared this additional knowledge with the practice team.

However, there were areas of practice where the provider must make improvements:

• Ensure that systems and processes are in place to ensure and record that all staff are safely employed. Not all practice staff who acted as chaperones or interpreters had received a disclosure and barring (DBS) check or written risk assessment. The management team did not have an accurate record of the DBS checks that had been received by clinical staff.

• Ensure that systems and process are in place to record the immunisation status of staff appropriate to their role.

• Ensure that systems and processes are in place to identify and mitigate risks relating to fire safety and legionella.

There were also areas of practice where the provider should make improvements:

• Maintain accurate records and oversight to ensure practice staff receive the training appropriate to their role and responsibilities.

• Ensure that information about how to complain is accessible for patients.

• Promote and encourage patients to take up national screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Dr H I Lazarus and partners is operated by Dr H I Lazarus and partners. Dr H I Lazarus and partners provide general practice services and a surgery service. This report relates only to the surgery service. All other services are reported on separately.

The service offers minor surgery, including vasectomy, removal of skin lesions and hernia repair to patients aged 18 years and over. Surgery is available all year round and is scheduled on an ad-hoc basis dependent on patient need and the availability of surgeons. Surgery services are limited to day surgery, with no facility for patients to stay overnight. Facilities include a patient waiting area, a pre-admission area, one operating theatre and a recovery area.

We inspected the service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 3 August 2017, along with a further inspection of the service on 10 August 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate minor surgery services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• Clinical areas were visibly clean. Staff were “bare below the elbow” and completed hand hygiene before and after contact with patients.
• Staff cleaned equipment daily, on the days when surgery was taking place. We checked a selection of equipment and found that it was visibly clean and marked with appropriately dated ‘I am clean’ stickers.
• Staff had access to policies online and also in paper format. We reviewed a selection of policies and found that they were version controlled, dated and included references to national guidance and law.
• Staff provided patients with guidance on pre-operative fasting for procedures requiring sedation and gave patients something to eat and drink after surgery if required.
• Staff monitored clinical outcomes, including pain control and infection rates, through local audit. Senior staff shared audit outcomes with staff and took action to improve outcomes based on audit results.
• We asked two patients about the care they received and both gave us positive feedback about the service. One patient commented that staff were “friendly and caring” and another described the service as “faultless.”
• Staff were kind and compassionate in their interactions with patients. We saw staff explaining a procedure to a patient and checking on their well-being during and after their operation.
• Hernia repair surgery was available on a Saturday, which meant that patients had flexibility to arrange their surgery outside of normal working hours.
• Staff were aware of the local population demographic, which included a high number of patients who did not speak English. Staff told us they would access translators from the GP practice for these patients.
• Information on how to complain was available to patients.The service had received one complaint from July 2016 to July 2017.
• Results of a staff feedback audit dated May 2016 showed that 100% of staff felt valued and were happy with communication from senior staff. We asked two staff about the leadership of the service. Both staff gave positive feedback about leaders and told us they would be confident to raise any concerns.

However, we also found the following issues that the service provider needs to improve:

• There were no clear inclusion and exclusion criteria to help staff assess patients’ suitability for the service. There had been an incident relating to an inappropriate referral, which resulted in a procedure being abandoned. This meant that there was a risk that patients with complex needs could be accepted to the service inappropriately. We raised this with senior staff at the time of inspection.They advised that this issue would be discussed at the next clinical governance meeting.
• Senior staff did not have direct oversight of the competency and appraisal of surgeons. No records of surgeons’ appraisals were kept on site and senior staff did not have contact with the the local NHS hospital where surgeons were separately employed regarding their competency. This meant that senior staff could not be assured of the ongoing competency of surgeons working in the service. We raised this with the general manager at the time of our inspection.
• The provider sent us records of surgeons’ compliance with mandatory training, which showed that none of the surgeons had completed all required mandatory training.
• Bank nursing staff were appraised at the local NHS hospital where they worked under separate employment. We saw results of a staff feedback audit dated May 2017, which showed that staff had asked to have an appraisal specific to their role in the surgery service. The theatre manager told us that appraisals for bank staff were planned to start in August 2017. This had not started at the time of our inspection.
• The theatre recovery area was located in the same room as a staff office area. Although the two areas were divided by a curtain, this was not an ideal environment as it may have impacted on patient privacy during recovery. We raised this with the theatre manager and general manager at the time of inspection. The theatre manager advised us that this area was not used as an office while patients were in the recovery area.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected the surgery service. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals