We carried out an announced comprehensive inspection at Warrior Square Surgery on 10 and 19 December 2018 as part of our inspection programme. The overall rating for the practice was inadequate. The full comprehensive report on the December 2018 inspection can be found by selecting the ‘all reports’ link for Warrior Square Surgery on our website at .

This inspection was an announced focused inspection carried out on 2 April 2019 to confirm that the practice was compliant with warning notices issued following the December 2018 inspection. Warning notices had been issued against regulation 12 (1) (safe care and treatment) and 17 (1) (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report also covers our findings in relation to the requirements against regulation 12 (1) (safe care and treatment) and regulation 17 (1) (good governance).

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.

The ratings remain unchanged from the December 2018 inspection as the purpose of the April 2019 inspection was to review compliance against the warning notices issued. We found the practice to be compliant against regulation 12 (1) (safe care and treatment), however they were not fully compliant against regulation 17 (1) (good governance).

Our key findings were as follows:

• The practice had acted to improve their systems in place for the safe management of medicines.
• Action had been taken to improve how the practice responded to national patient or medicine safety alerts, including a record of action. However, the systems for sharing information about alerts were informal and did not guarantee that all relevant staff understood the alerts and action taken.
• There were improvements to the recording of significant events and complaints along with the action taken as a result.
• There were improvements to the systems for acting on correspondence from secondary care and evidence that a revised protocol around this was working effectively.
• There were improvements to the availability of appointments and systems of prioritisation in relation to this. The practice had developed a policy to respond to unwell children and had provided training and support to reception staff about this.
• Clinical audits had been repeated to demonstrate improvements as a result.
• Outcomes of care and treatment were monitored but there was limited evidence of improvement in the areas highlighted in the previous inspection. Childhood immunisation rates had deteriorated since December 2018.
• There were improvements in systems to assess, monitor and manage risks to patient safety, however we found that action recommended following a legionella risk assessment had not been carried out.
• There were improvements to review and management of practice policies, records relating to complaints and significant events.

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.

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

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Warrior Square Surgery on 10 December 2018 as part of our inspection programme. We undertook a second inspection day on the 19 December 2018 to gather additional evidence on 10 December 2018.

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.
• There were gaps in systems to assess, monitor and manage risks to patient safety.
• The practice did not have a clear policy to respond to unwell children and not all reception staff were aware of the ‘unwritten’ expectation of providing unwell children with on the day appointments.
• Staff did not have the information they needed to deliver safe care and treatment.
• 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:

• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Some performance data was significantly below local and national averages.

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

• Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
• 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.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not act on appropriate and accurate information.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as inadequate.

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

• People were not always able to access care and treatment in a timely way, although we saw that the practice had worked to make some improvements in this area.
• Complaints were not always responded to and used to improve the quality of care.

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 areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• 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 the duties.
• Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

• Work to increase the membership of the patient participation group to reflect the practice population.

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

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