This practice is rated as requires improvement overall. (Previous rating February 2018 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at St Lukes Surgery on 21/08/2018 to follow up on breaches of regulations. The practice had previously been inspected in February 2018, when it was rated Inadequate overall. Specifically, the practice was rated as inadequate for providing safe, effective, responsive and well-led services. The practice had been rated as good for providing caring services. The practice was placed in special measures.

At this inspection we found:

• There was a new approach to the running of the practice with an open and transparent approach to safety and an effective system in place for reviewing and recording areas for improvement.
• The practice was in the process of merging with another GP practice, the Living Well Partnership. The practice had commenced the merger with the Living Well Partnership in October 2017 to promote sustainability and to share services for patients. We found that the merger of shared systems and processes had almost been completed.
• Senior managers had assumed responsibility for overseeing different areas of governance and leadership and had implemented an organisation hierarchy of line management and accountability.
• The practice had implemented 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 and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• There were gaps in staff training and not all staff had received an annual appraisal.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient feedback regarding the ease of accessing care remained mixed. The practice had made some changes to improve access for patients but new systems were not embedded.
• Staff reported feeling well supported by leaders and there was a focus on continuous learning and improvement at all levels of the organisation.

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

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out duties.
• 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:

• Continue to review prescribing for some less recommended antibiotics to reduce the number of items prescribed, in line with local and national averages.
• Review processes which enable staff to access policies and procedures.
• Review registration to reflect changes made to the provider and partners.

This service was placed in special measures in February 2018. Sufficient improvements have been made such that St Lukes Surgery has now been rated as Requires Improvement. 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

This practice is rated as inadequate overall. (Previous inspection February 2018 – Inadequate. Inspection December 2016 - Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – good

Are services responsive? – Inadequate

Are services well-led? - Inadequate

The practice was rated inadequate overall at the February 2018 inspection and placed into special measures. As a result of the February inspection two warning notices were served. The timescale given to comply was 13 April 2018. The warning notices related to regulation 12 (safety) and regulation 17 (good governance) of the Health and Social care Act.

We carried out an announced focused inspection at St Lukes Surgery on 24 April 2018. This inspection was to follow up on the enforcement action we undertook as part of the inspection on 12 February 2018.

At this inspection we found:

• The practice had commenced improvements in response to the warning notice however further work is indicated to ensure that the improvements continue and are sustained.
• In relation to policies, procedures and processes around infection prevention and control some changes had been implemented although work was still ongoing to ensure all had been updated and embedded into practice.
• The practice had revised processes for stock control and emergency medicines in order to improve patient safety.
• The practice had recruited for several key vacancies and had temporary staff in place to fill gaps for any recruitment still ongoing.
• The practice had reinstated the weekly respiratory clinic for patients with the first appointments due to be held soon after the inspection.
• The practice had improved processes for monitoring actions identified from risk assessments and learning from complaints.
• The practice had improved monitoring of patient feedback and created action plans to begin to address concerns raised.
• Systems for maintaining oversight of staff training and recruitment remained incomplete and were not fully embedded into practice.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

This service remains in special measures will be inspected again within six months of the February 2018 report publication. 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.

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

This practice is rated as Inadequate overall. (Previous inspection December 2016 – Good)

The key questions are rated as:

Are services safe? – inadequate

Are services effective? – inadequate

Are services caring? – good

Are services responsive? – inadequate

Are services well-led? - inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. Due to the overall rating being inadequate this affects all population groups which 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

We carried out an announced comprehensive inspection at St Luke’s Surgery on 12 February 2018. This inspection was planned as part of our inspection programme but was brought forward in response to concerns.

At this inspection we found:

• Since our last inspection the practice had sought support through another GP organisation for some management practices, this had been in place since October 2017. Patients were told there had been a merger; however, this is limited to the provision of support from Living Well Partnership. The registration of St Luke’s remains in place and patients can only be seen where they are registered or at an out of hours hub.

• The leadership at St Luke’s Surgery had declined and there was no longer a registered manager.

• There was a lack of clear leadership to deliver the practice’s vision and strategy. Staff turnover had resulted in a number of vacancies including for senior or middle management and clinical roles.

• The practice had an information security breach in the few days before our inspection that was publicised on their website.

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen.

• Risk assessments were in place but not always reviewed or updated. There was no action plan to address issues raised at the last infection control audit dated March 2017.

• Not all staff had a record of having completed safeguarding training.

• Weekly fire tests had not been documented as being carried out since 24 November 2017 at the branch site.

• The quality of information captured and evidence of learning from significant events was limited.

• The practice had higher than average exception reporting levels for several clinical indicators.

• There was limited evidence that the practice was engaging in quality improvement programmes.

• There were vacancies in the nursing team resulting in a gap in skills mix for monitoring of long term conditions such as asthma.

• Staff involved and treated patients with compassion, kindness, dignity and respect. There was mixed feedback from patients about the quality of care they felt they received.

• Patients found it difficult to use the appointment system and reported that they were not able to access care when they needed it. There was limited evidence to demonstrate how the practice was responding to concerns raised by patients around accessing the service.

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.

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

• Review survey results to identify what can be done to improve patient satisfaction.

• Review ways to identify and support patients registered at the practice who are also carers.

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

Letter from the Chief Inspector of General Practice

We carried out a focused follow up inspection of St Lukes Surgery on 1 December 2016. This inspection was performed to check on the progress of actions taken following an inspection we made on 18 November 2014. These included;

• Having effective recruitment procedures to ensure all necessary checks are made prior to a new member of staff commencing employment. This included obtaining satisfactory information for locum GPs.

• Recording medicine refrigerator temperatures as specified in the practices policy.

Following the inspection in November 2014 the provider sent us an action plan which detailed the steps they would take to meet their breaches of regulation. During our latest inspection on 1 December 2016 we found the provider had made the necessary improvements in delivering safe services.

This report covers our findings in relation to the requirements and should be read in conjunction with the comprehensive inspection report published in March 2015.. This can be done by selecting the 'all reports' link for St Lukes Surgery on our website at www.cqc.org.uk .

Our key findings across the areas we inspected in this focused follow up inspection were as follows:

• There were now effective recruitment procedures ensuring that all necessary checks were made prior to a new member of staff commencing employment. This included obtaining

  satisfactory information for locum GPs.

• Patient safety was improved through the monitoring of medicine refrigerator temperatures, which was monitored and recorded daily.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of this service on 18 November 2014. We have rated the practice as good overall.

The practice delivered effective care and treatment to its patients. We saw clear management systems in place and staff were able to contribute to the running of the practice.

Our key findings were as follows:

• The practice was visibly clean and there were systems in place to maintain an appropriate standard of cleanliness and hygiene.
• Patient requirements were taken into account when services were planned and delivered. These included availability of appointments outside of working hours and home visits when needed.
• GPs and nurses received appropriate training and support to deliver care and treatment.
• The practice routinely assessed and monitored the quality of its service and took action when needed to improve.
• Patients with learning disabilities were routinely offered home visits and picture cards were used to assist in explaining what treatment was needed.
• The practice had links with a community health team who collected vaccines from the practice and administered them to patients registered with the practice, who were housebound or lived in care homes.
• Grandparents who looked after their grandchildren were offered a session on basic life support

We saw areas of outstanding practice including:

• The practice had developed a mobile telephone application which informed patients of appointment availability and with which GP.
• Patients with learning disabilities were routinely offered home visits and picture cards were used to assist in explaining what treatment was needed.

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

Importantly, the provider must:

• Must ensure that for locum GPs there is all required recruitment information.

In addition the provider should:

• Record medicine refrigerator temperatures as specified in their own policy

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice