This practice is rated as requires improvement overall. (Previous rating December 2017 – Inadequate)

Sutherland Lodge Surgery was previously inspected in December 2017 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, responsive and well-led services. As a result of the risk identified at this inspection, we asked the provider to take immediate action to mitigate the risks. We then carried out a focused inspection on 10 January to check whether the provider had taken appropriate action to lower the risk. We found that they had done so. We then issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

We reviewed the areas covered within the warning notice during an unrated focused inspection in July 2018 and found that they had complied with the warning notice.

We carried out an announced comprehensive inspection at Sutherland Lodge Surgery on 13 November 2018 to follow up on breaches of regulation.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement (for patients with long-term conditions, those experiencing poor mental health and those who were vulnerable)

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

At this inspection we found:

• Since the previous inspection where the practice was rated inadequate, systems and processes had been strengthened to provide patients with safe care and treatment.
• There was stronger leadership and governance in place and the leaders had clear oversight of clinical performance and risks to patients.
• Staff we spoke with on the day felt the leaders of the practice shared and informed them of relevant information.
• The practice had strengthened their systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, lessons learnt were shared with staff. Although lessons learnt had been documented and shared there was minimal evidence to portray changes that had been implemented as a result of safety incidents.
• Practice leaders had oversight of incidents, and complaints. We found that actions had been implemented following a complaint or incident however the actions were not reviewed to ensure they reduced the likelihood of the same events occurring again.
• The practice had completed most actions required from environmental risk assessment however we found that the health and safety risk assessment was difficult to follow and did not document actions that had been completed.
• The practice had implemented systems to safeguard patients from abuse, however, we found there were areas within their process that required strengthening.
• The practice took consent appropriately. We found that consent had been documented on patient notes and written consent was being taken appropriately for surgical procedures.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• Although the practice carried out multiple audits to monitor care, we found that there was an inconsistent approach to NICE guidelines.
• We found occasionally information from discharge letters had not always been followed up.
• Patients with complex needs such as learning disabilities were not receiving their care in line with guidance.
• We found that there was an inconsistent approach to carrying out annual health checks. QOF data published in 2017/18 found the practices clinical performance indicators for patients with long term conditions and mental health were below local and national averages. The practice was aware of their clinical performance and had implemented a process to improve their performance indicators.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients reported that they were able to access care when they needed an appointment however there was mixed reviews regarding the telephone access. Survey data for 2017/18 was comparable with local and national averages.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

The practice had gained funding from the provider to create ‘positivity packs’ which were designed to help vulnerable patients such as those with mental health conditions and the homeless. Staff at the practice were proud of the work they had achieved and had received feedback from patients that the packs had helped them through vulnerable situations.

The areas where the provider must make improvements are:

• 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 develop systems to ensure that learning from safety events and complaints results in change where required.
• Improve systems to document risk assessments and actions taken.
• Continue to strengthen process to improve workflow management for reviewing and actioning incoming correspondence.

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

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced, comprehensive inspection of Sutherland Lodge on 7 December 2017. At this inspection, we found a number of areas of serious concern relating to risk management and patient safety. We spoke with the provider about our findings and asked them to send us an action plan to assure us that the areas of high risk that we found on inspection were being managed effectively and the risks to patients reduced.

As a result of the action plan sent to us on 22 December 2017, we found that the provider had identified measures to reduce the risks to patients.

We then carried out an unannounced focused inspection on 10 January 2018 to check whether the service had implemented their action plan effectively and made sufficient progress to reduce the risk to patients, since the last inspection on 7 December 2017 and to enable us to assess the level of enforcement action we needed to take. This report covers our findings.

The practice was not rated as part of this inspection and we only looked at areas where risk was assessed as high, as a result of the last inspection.

Our key findings were as follows:

• Not all clinical staff had received safeguarding training at a level required for their role.
• There was an effective system to manage infection prevention and control.
• Letters from secondary care were acted on in a timely manner.
• Medicines are being stored safely in accordance with manufacturer’s instructions.
• Staffing levels and skill mix had been reviewed; however staffing levels and skill mix did not compare with the planned levels identified by the provider.
• An audit had been completed on medicines that were known to be open to misuse. A protocol to assist GPs in reviewing patients on these medicines had been implemented.
• The practice had acted on the fire risk assessment recommendations.
• The practice had reviewed some significant events, however actions and lessons learnt were not being cascaded to all staff.
• Patients continued to have trouble in accessing the practice and receiving urgent clinical advice.
• There was a lack of systems to identify, escalate and action clinical risk. This included ill children and those who were seriously unwell.
• Patients who made a complaint were receiving a timely response.
• There remained a lack of oversight of clinical performance and some risks were not identified or managed effectively.
• Medicines audits had been completed although there had been no clinical audits scheduled for the next 12 months.
• Audits and processes were in place to monitor patients on high-risk medicines.
• Information cascades were not effective. Not all staff attended practice meetings or received minutes of these.
• Procedures in relation to patient medicine alerts had been reviewed, and appropriate action taken to ensure patients were safe.
• The practice had not implemented their own action plan within the timescales they identified in their action plan.

We were satisfied that the findings at this inspection reduced the risk to patients to a level where significant enforcement action was not required. The provider was continuing to make improvements as identified in their action plan.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Sutherland Lodge Surgery was previously inspected in December 2017 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, responsive and well-led services. As a result, we issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

We carried out an announced focused inspection at Sutherland Lodge Surgery on 04 July 2018. The focused inspection was to review whether the provider had made improvements and was compliant with the warning notice. We also looked at the governance arrangements and the leadership of the practice. The practice was not rated at this inspection.

At this inspection we found:

• The practice had systems in place to safeguard adults and children. Progress was being made to strengthen links with other agencies to appropriately share knowledge of risk.
• The practice had 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. We found that not all staff were familiar with reporting a significant event.
• 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.
• Complaints were investigated appropriately and learning shared. Although, the sharing process for this could be improved as evidence of review in meeting minutes was minimal.
• There was stronger leadership and governance in place and the leaders had a clear oversight of clinical performance and risks to patients.
• The overall culture was improving however, some staff spoken with did not feel their views were always listened to.

The areas where the provider should make improvements are:

• Continue to monitor and review the new systems and processes to ensure that improvement can be sustained over the long term.
• Continue to develop systems to ensure that learning from significant events and complaints is shared with all staff. Ensure all staff are aware of the reporting procedure for a significant event.
• Continue to seek and act on the views of staff where relevant, to improve services.

The practice had made effective improvements and had complied with the warning notice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

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. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently 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 Sutherland Lodge on 7 December 2017, as part of our inspection programme and in response to concerns, raised directly with us relating to patient access, the quality of treatment, the management of prescriptions and delays in referrals.

As a result of the findings at this inspection, we asked the provider to take action to reduce the more concerning risks by 22 December 2017 and we then carried out a further focused inspection on 10 January 2018, to check whether the risks to patients had been reduced. We found that they had. The report of this inspection has not yet been completed at the time of writing this report, but it will be published on our website in due course.

Our key findings at the inspection on 7 December 2017 across all the areas we inspected were as follows:

• Systems, processes and practices to keep people safe and safeguarded from abuse were unreliable. Clinical staff were not trained to the correct level recommended by guidance.

  Also clinical staff did not always adhere to or have sufficient knowledge of the Mental Health Act Code of Practice.

• Some of the key requirements from the Health and Social Care Act 2008 Code of Practice on the prevention and control of infection were not being met.

• Risks to patients were not being appropriately assessed, or their safety monitored and managed so they were supported to stay safe. There was a lack of clinical oversite to ensure information received regarding new diagnosis and medicine changes were not completed in a timely way.

• Staff were aware of their responsibilities to manage emergencies on the premises and they had up to date information on how to identify and manage patients with severe infections, for example, sepsis.

• Medicines and associated equipment were not always in date or stored at the correct temperature and nursing staff tasked with monitoring did not take action when temperatures were above recommended levels.

• Arrangements in place to receive and comply with patient safety alerts, recalls and rapid response reports were ineffective. There was no process to ensure safety alerts were actioned and patients informed if they were at risk.

• There had been no significant events identified therefore there was no evidence of learning from incidents to improve quality. Opportunities to analysis, action change and share outcomes were missed.

• Patients with complex needs for example learning disabilities and older patients were not receiving their care in line with guidance. For example care plan reviews and health checks.

• Medicine reviews were not always taking place. There were inconsistent reviews of high-risk medicines and action to address risks was not always in line with national guidance.

• There was a corporate system for the handling of complaints. However, this did not include cascading the learning to staff working at the practice or ongoing monitoring. Action was not always taken to improve the quality of care as a result.

• Some outcomes for patients were below local and national averages. Participation in audits and quality assurance processes was limited.

• Patients reported there was a lack of continuity of care and we saw that this had a detrimental impact on the quality of patient treatment and care.

• Services were not always planned or delivered in a way that met patient’s needs. There was no evidence the service took account of patient preferences.

• Appointment systems were not working well so patients did not receive timely care when they needed it, particularly in relation to GP home visits. Patient survey results and CQC comment cards identified patients had concerns about access to GP appointments and getting through to the practice by phone.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

• Risks within the practice were not effectively managed and risk assessments were either unavailable or insufficient. Staff responsible for the management of risks and health and safety were not aware of the scope of these responsibilities.

• Policies and procedures were not always accessible, clear or up to date.

• There was uncertainty amongst staff due to unclear changes in relation to the registered provider and a subsequent impact on the staffing structure within the practice.

• There were accessible facilities, which included a hearing loop, and interpretation services available.

The areas where the provider must make improvements are:

• Ensure there are systems to assess, monitor, manage and mitigate risks to the health and safety of patients who use services.

• Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.

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

• Ensure the proper and safe management of prescribing medicines. This is to include repeat prescribing and monitoring of high-risk medicines.

The areas where the provider should make improvements are:

• Ensure there were systems for assessing the risk of, and preventing, detecting and controlling the spread of infections. Monitor and schedule cleaning of areas where debris collects.

• Continue to review how the practice could proactively identify carers in order to offer them support where appropriate.

• Review the current processes for engaging with the practice population to encourage patients to feedback on services.

• The provider should actively seek the views of a wide range of stakeholders, including people who used the service. The provider did not analyse patient feedback or made improvements.

• Ensure that equipment used by the service provider for providing care or treatment to a service user was safe for such use. Checks for out of date equipment should be made frequently.

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 vary the provider’s registration 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