We previously carried out an announced comprehensive inspection at The High Street Surgery on 23 April 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for six months. This was because systems were not effective in managing patients on high risk medicines, patient safety alerts, complaints, health checks, overall performance, recruitment checks, working with others and patient access generally.

Following that inspection, the practice was served with a warning notice in respect of the governance at the practice. At a subsequent inspection of 11 September 2018, the practice we found to have met the requirements of that warning notice.

We carried out an announced comprehensive inspection at The High Street Surgery on 08 January 2019. At this inspection we followed up on breaches of regulations identified at our previous inspection on 23 April 2018 and rerated the practice.

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.

This practice is now rated as requires improvement overall.

We rated the practice as requires improvement for safe because;

• Not all checks were undertaken when locums were engaged.
• The nurse prescriber’s remit was unclear and systems to audit their consultations was uncertain.
• Adequate plans had not been put in place to meet patient demand after the imminent departure of a member of the clinical team.

We rated the practice as requires improvement for effective because;

• Continued action was required in respect of the care of patients with diabetes and poor mental health.
• There were no formalised systems to supervise the nurse practitioner.
• The high-risk medicines policy was not specific to the needs of the practice.

We rated the practice as requires improvement for responsive because;

• Whilst an action plan had been implemented, verified data was not yet available to evidence improvement in patient satisfaction, as identified in the national GP patient survey. All the population groups in this domain are also rated as requires improvement as patient satisfaction affects all these groups.

We rated the practice as requires improvement for well-led because;

• Continued action was required to ensure that risks to patients had been identified in relation to the use of locums, performance in the review of patients with diabetes and those suffering with poor mental health and patient satisfaction. Further, the practice was facing a period of instability in the team and action plans had not been revised to take this into account.

We rated the practice as good for providing caring services because;

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

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

The areas where the provider should make improvements are:

• Evidence reviews of the nurse prescriber’s consultations and formalise systems for supervision.
• Ensure information to patients accurately reflects the nurse prescribers’ job title.
• Review the high-risk medicines policy so that this is specific to the requirements of the practice.
• Formalise the policy to confirm the identification of patients who request prescriptions over the telephone.
• Identify more patients who are carers.

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

We previously carried out an announced comprehensive inspection at The High Street Surgery on 23 April 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for six months. The full comprehensive report on the 2017 inspection can be found by selecting the ‘all reports’ link for The High Street Surgery on our website at .

Following that inspection, the practice was served with a warning notice in respect of the governance at the practice.

This inspection was an announced focused inspection carried out on 11th September 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.

We found that the practice had met the requirements of the warning notice.

Our key findings were as follows:

• Significant events were being recorded and reviewed, including those which were clinical in nature.
• Complaints, including verbal complaints, were recorded and managed appropriately.
• A patient participation group (PPG) had been formed with a view to obtaining meaningful feedback about the services being delivered.
• There were now more clinical sessions. The next appointment with a GP was in less than two weeks’ time. This demonstrated improvement as at our last inspection, there was a four and a half week wait for a routine appointment with a GP.
• Frequent meetings were taking place which included all staff. Safety alerts, NICE guidelines, significant events and complaints were routinely discussed. There were now regular meetings with other healthcare professionals to discuss patents of concern.
• Reviews had taken place to ensure that patients were prescribed medicines safely and in line with guidance.
• Nurses involved in chronic disease management attended regular meetings. All members of the nursing team who were currently working at the practice had received an appraisal of their performance.
• Patient group directions (PGDs) were now being completed correctly.
• Staff received training relevant to their role.
• Infection control procedures had been reviewed. An action plan had been completed to identify where improvements were required.
• Recruitment checks were now being completed, as were DBS checks for staff who acted as chaperones.
• There were action plans in place to improve QOF performance. Unverified data indicated improvements had been made when compared to the same period in 2017.
• Effective governance arrangements had been implemented.

Professor Steve Field CBE FRCP FFPH FRCGP

This practice is rated as inadequate overall.

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

We carried out an announced comprehensive inspection at High Street Surgery on 23 April 2018. This was carried out as part of our inspection programme.

• The practice did not have clear systems to manage risk so that safety incidents were less likely to happen.
• Systems to safeguard vulnerable adults and children from abuse were not effective.
• Staff were not safely recruited or effectively trained for their role.
• Staff who acted as chaperones had not received a DBS check or risk assessment to ascertain their suitability for the role.
• Systems did not ensure the security of patient data.
• There was not an effective system to manage infection prevention and control.
• Patient group directions (PGDs) were not being completed correctly.
• There was not an effective system for acting on patient safety and medicine alerts.
• There were systems to monitor patients who were prescribed high-risk medicines.
• Meetings with healthcare professionals to discuss and review patients of concern had not taken place this year. There were no regular meetings or systems for clinical support for the nurses.
• The practice manager and the advanced nurse practitioner had not received a recent appraisal of their performance.
• Prescribing for antibiotics was comparable with the CCG and England average.
• The practice did not have systems to keep clinicians up to date with current evidence-based practice.
• No quality improvement activity had taken place.
• QOF data for 2016/17 was below average in respect of checks for patients with diabetes and hypertension. The practice was also below average for some mental health indicators. Unverified data for 2017/18 did not indicate consistent improvement.
• Cover arrangements were not in place for two members of the clinical team who had given notice of planned long-term leave.
• Some staff did not always have the skills, knowledge and experience to carry out their roles.
• The practice manager was in the process of obtaining additional training with a view to improving their training processes.
• The practice offered some routine health checks to patients aged over 75 and to those with a learning disability in order to offer them advice and support about how to live a healthier life.
• The most recent results from the July 2017 GP survey were in line with averages in respect of the care provided. Results were below average in relation to the accessibility of services.
• On the day of our inspection, there was a four and a half week wait for a routine appointment with the GP.
• Systems to respond and manage complaints were inadequate. No action was taken by the practice to improve care.
• Staff morale was low. There were not always positive relationships between the clinical teams.
• Leadership was inadequate as there was a lack of oversight and implementation of effective policies and procedures. The provider registered with the CQC in January 2018 as an individual provider of regulated activities at this location. Previously, the provider had been in a partnership with one other GP partner at this practice. They had failed to display that they were sufficiently aware of the challenges and performance faced and did not have action plans in place to improve.

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.

The areas where the provider should make improvements are:

• Appraise the advanced nurse practitioner and the practice manager.
• Make the complaints policy available on the practice website.
• Take steps to identify more patients who are carers and offer them appropriate support.
• Take steps to improve feedback from the GP patient survey in respect of access.

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 FRCGPChief Inspector of General Practice