Suffolk GP Federation C.I.C., the registered provider of this service. Suffolk GP Federation C.I.C is a community interest company and is the registered provider of three other locations and services are provided from various sites across Suffolk.

Walton Surgery (referred to in this report as ‘the practice’) was previously inspected in January 2019 and is rated as inadequate overall. The practice was issued with a warning notice for Regulation 12, safe care and treatment. We carried out an announced focused inspection at Walton Surgery on 8 May 2019, to check that the practice had complied with the warning notice. The practice had met the requirements of the warning notice. The key questions at this inspection are not rated.

At this inspection we found:

• Equipment had been calibrated and a system established to monitor when this was due to be re-calibrated.
• Systems had been established for managing incoming patient correspondence, coding and to ensure that test results for cervical cytology were monitored and acted upon. Managerial and clinical audit of this work had been established and scheduled.
• We reviewed the practice’s computer system and found there was no outstanding patient correspondence. Systems were in place to check patient correspondence had been managed in a timely way.
• Assurance systems to check the competency of clinical staff had been established and implemented and findings had been discussed with staff. These checks were due to be undertaken on a quarterly basis.
• Patients had been prioritised for medicines reviews according to their risk factors. An alert had been added on the practice’s computer system to alert clinicians to the possibility of specific side effects, linked to specific medicines.
• Systems were in place to ensure monitoring was undertaken for medicines which required this, before being re-issued. Appropriate monitoring had been undertaken for the patients we reviewed.
• The systems which had been established following our previous inspection needed to be embedded.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Walton Surgery on 23 May 2017. Overall the practice is rated as good.

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

• On the 4 November 2016, Suffolk GP Federation became the registered provider of Walton Surgery. The practice staff we spoke with told us significant improvements had been made, including the employment of a new GP clinical lead.
• There was a clear leadership structure, which was understood by the staff we spoke with. They told us the clinical lead GP and practice manager had involved them in developing their practice vision and future development plans to offer greater services to their patients.
• The practice proactively sought feedback from staff and patients, which it acted on.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events at practice level, and for escalating through to the appropriate board within Suffolk GP Federation.
• The practice had systems to minimise risks to patient safety. A detailed practice improvement plan was used to ensure improvements were made in a timely way and any risks updated regularly. The practice and the Federation regularly reviewed this plan.
• Practice staff were aware of current evidence based guidance, and had been trained to provide them with the skills and knowledge to deliver effective care and treatment. The clinical staff discussed these and patient cases at regular meetings.
• Results from the national GP patient survey, published in July 2016, showed patients were treated with compassion, dignity, and respect and were involved in their care and decisions about their treatment. The practice used an electronic console to collect feedback from patients at every opportunity.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day. Extended hours appointments were available at the practice on Wednesday evenings. The practice, in collaboration with two local practices, offered same day appointments at Felixstowe community hospital. The practice was also part of a GP+ service; patients were able to be seen for evening or weekend appointments at Felixstowe Community Hospital and a location in nearby Ipswich.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw areas where the practice should make the following improvements:

• Review the management of legionella and ensure any actions needed in relation to low water temperatures are completed in a timely way.

• Continue to embed all new policies and procedures to ensure performance and quality is monitored.

• Continue to embed the schedule of audits to ensure the practice monitors performance and encourages improvement.

• Improve the system for monitoring staff training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

The practice is rated as Inadequate overall. The practice was previously inspected in June 2017 and rated as good.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Walton Surgery on 23 January 2019 (referred to in this report as ‘the Practice’) as part of our inspection of Suffolk GP Federation C.I.C., the registered provider of this service. Suffolk GP Federation C.I.C is a community interest company and is the registered provider of three other locations and services are provided from various sites across Suffolk.

Our judgement of the quality of care at this service is based 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.

At this inspection we found:

• Patients were supported, treated with dignity and respect and were involved in decisions about their care and treatment.
• Results from the national GP patient survey published in July 2018 were in line with local and national averages. Results for access were above local and national averages.
• Patients’ needs were met by the way in which services were organised and delivered. For example, Suffolk GP Federation C.I.C. had worked with two other local practices and had access to two full time mental health nurses and a paramedic. The three practices worked together to deliver an ‘on the day’ service from 3pm to 6.30pm to offer urgent appointments for patients.
• Feedback from patients on the day of inspection, including CQC comment cards, was positive about the care received by the practice.

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

• There was insufficient attention to safeguarding. They practice held a register of patients where safeguarding concerns had been raised, although the safeguarding lead was not aware of this and did not know how to access it, and they did not hold regular safeguarding meetings.
• The information needed to plan and deliver safe care, treatment and support was not available at the right time. For example, patient correspondence was not managed in a timely way. The practice had 358 items of outstanding correspondence; some patients had not been followed up in a timely way, major, significant health needs had not been coded on their medical record and diagnostic reports had not been reviewed or coded.
• There was not a failsafe system to monitor cervical cytology.
• The practice did not have adequate systems and processes in place to ensure appropriate monitoring was in place before medicines were reissued.
• We found some of the medical equipment for one of the GPs had not been calibrated.
• The external clinical waste bin was not locked and the practice did not have a spill kit for cleaning up mercury.

We rated the practice as inadequate for providing effective services, and across all population groups, because:

• There was not a system at the practice level to ensure safeguarding was managed effectively.
• The information needed to plan and deliver effective care, treatment and support was not available at the right time. We were not assured that care and treatment decisions were always based on accurate information, due to the outstanding correspondence, which included some patients with major, significant health needs who had not been coded on their medical record and diagnostic reports which not been reviewed or coded.
• Evidence based practice was not always followed in relation to monitoring and review of patient medicines.
• There was no regular documented monitoring of the work of nurses and the advanced nurse practitioner. We found recent examples when a clinician had worked outside of their competency.
• There was limited monitoring of the outcomes of care and treatment at practice level. Performance for diabetes was below the CCG and England averages and the exception reporting for mental health was above the CCG and England averages. The clinical lead at the practice was not aware of this and was not able to explain this.
• Older people who were identified as frail, did not receive a clinical review.
• Three out of nine eligible patients with a learning disability had received a health review in the last 12 months.
• There was no palliative care register or clinical oversight of patients with palliative care needs.

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

• Despite the Suffolk GP Federation C.I.C. having systems and processes in place to try and ensure leadership and governance across the organisation, this was not effective as there was a lack of clinical leadership and oversight at the practice level to ensure that the service operated safely and effectively.
• There was a lack of systematic performance management of individual staff to ensure safe practice was being observed.
• There was a lack of oversight from Suffolk GP Federation C.I.C. to ensure that systems and processed were being followed. We identified that governance systems and processes in place were not always followed by staff which did not support the safe and effective care of patients.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure patients are protected from abuse and improper treatment.
• 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 work with the CCG in relation to prescribing, particularly with the prescribing of broad spectrum antibiotics.
• Review the system for tracking prescription stationery.
• Continue to improve the uptake of health checks for people with a learning disability.

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 FRCGPChief Inspector of General Practice