We carried out an announced comprehensive inspection at The Great West Surgery on 6 December 2018 as part of our inspection programme. We had also received concerns from staff (anonymous) and patients who reported concerns about the service which we followed up. We were also made aware that the practice had been issued with a contractual breach notice by the commissioner for not providing sufficient GP appointments.

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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• Receptionists and staff had not been given guidance on identifying deteriorating or acutely unwell patients.
• Not all administrative staff had received appropriate safeguarding training.
• Recently recruited administrative staff had not received an effective induction.
• The practice did not have appropriate systems in place for the safe management of medicines.
• The practice did not learn and make improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

• The practice could not show that care was provided in line with current guidelines and best practice.
• There was limited monitoring of the outcomes of care and treatment and unusual variation identified in exception reporting.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

We rated the practice as inadequate for providing responsive services because:

• Patients had difficulty accessing the service by telephone.
• Patients reported difficulty making a complaint.
• The practice could not show that it was learning and making timely improvements to the service following complaints.

We rated the practice as inadequate for providing well-led services because:

• While the practice had a clear vision, that vision was not supported by a credible strategy.
• The practice culture did not effectively support high quality sustainable care.
• The overall governance arrangements were ineffective and confused at local level.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• The practice did not have embedded systems and processes for learning or for continuous improvement and innovation.

These issues affected all population groups in particular and we rated the population groups as inadequate.

We rated the practice as requires improvement for providing caring services because:

• The practice consistently scored lower than average on the national GP patient survey.
• The practice had identified patients who were carers including some young carers. It did not actively maintain a carers’ register and staff were not always clear about the support they could offer to carer.

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The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review staff understanding of the services the practice can offer to patients who are 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.

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

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