Archived: Cornwallis Surgery

Updated 16 November 2017

The Cornwallis Surgery was taken over by a single GP in July 2015 when the location was in special measures. At the time the practice engaged with a consultant firm who provided some managerial support. In October 2015 the practice merged with another within the same building and the provider also took over three further surgeries in the Hastings area, Little Ridge, Shankill and Essenden Road which are run as branch surgeries. The practice is not currently accepting new patients and has approximately 17,500 patients registered.

In February 2015 CQC carried out a comprehensive inspection after which the practice was rated requires improvement overall, requires improvement in the effective, caring and well-led domains

and good in the safe and responsive domains. The practice was taken out of special measures.

On 1 September 2016 the consultancy organisation assisting with back office support withdrew and a second GP joined the practice and took over the role of clinical lead GP (male). In April 2017 CQC carried out an unannounced focused inspection to confirm that the practice had taken steps to meet the legal requirements in relation to the breaches in regulations that we identified on our previous inspection on 1 November 2016 and to respond to a number of concerns sent to the Care Quality Commission. The practice was rated as inadequate following this inspection and placed into special measures. The clinical lead GP left the practice and since then the GP cover has been provided by locum GPs with remote input from the registered provider and support through the CCG from GPs from other local practices.

The practice also employs two nurse prescribers (female) one of whom is a community nurse practitioner who triages and carries out home visits. There is one practice nurse (female) and two regular agency practice nurses (male and female), three health care assistants (female) and one phlebotomist. The onsite management team are made up of a chief operating officer, general manager and reception supervisor based at Cornwallis Plaza and an assistant manager based at Shankhill Surgery.

Practice opening hours are:

Cornwallis Plaza Surgery 8-6.30 Monday to Friday

Shankill Surgery 8-6 Monday; 8-5.30 Tuesday; 8-1 Wednesday and Thursday; 8-5.30 Friday.

Little Ridge Surgery 8-6.30 Monday, Wednesday, Friday; 8-1 Tuesday and Thursday

Essenden Road Surgery is currently closed to patients.

When the surgeries are closed patients can access the out of hours service by phoning 111.

Services are provided at:

Cornwallis Surgery, Station Plaza Health Centre, Station Approach, Hastings East Sussex. TN34 1BA.

Essenden Road Surgery, 49 Essenden Road, St Leonards-on-Sea, East Sussex, TN38 0NN. At the time of the inspection Essenden Road Surgery was closed to patients.

Little Ridge Surgery, 38 Little Ridge Avenue, St Leonards-on-Sea, East Sussex, TN37 7LS.

Shankill Surgery, 21 Fairlight Road, Hastings, East Sussex,TN35 5ED.

Updated 16 November 2017

Letter from the Chief Inspector of General Practice

We carried out an unannounced focused inspection in response to concerns at Cornwallis Surgery on 7 September 2017, raised directly with CQC relating to patient access to and the quality of treatment, the management of prescriptions and delays in plans to transfer services to a new provider. We then conducted this inspection as a comprehensive inspection due to the findings of our focused visit and returned for a second unannounced visit on 11 September 2017.

During this inspection we identified risk of harm to patients due to insufficient staffing numbers and lack of effective governance processes and systems to identify, assess and monitor risk. This was a breach of legal requirement and the practice was rated inadequate providing safe, effective, caring, responsive and well-led services and overall. As a result of this inspection the Care Quality Commission has imposed urgent conditions on the registration of the service provider under Section 31 of the Health and Social Care Act 2008, in respect of all regulated activities for which they are registered. The urgent action was taken as we believe that a patient will or may be exposed to the risk of harm if we did not do so.

Our key findings across all the areas we inspected on 7 and 11 September 2017 were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice had not carried out appropriate recruitment checks on locum GPs.
• Medicines and associated equipment were not always in date or stored securely and nursing staff tasked with monitoring did not have the time or capacity to do this. Blank prescriptions were not always stored securely.
• The practice had systems in place for collecting and collating significant events and complaints and there was a culture of reporting incidents within the practice.
• Staff reported incidents, near misses and concerns within the practice but there was no evidence of learning and communication with staff. Clinical incidents did not have the appropriate level of clinical input and staff were unsure about notifiable incidences and where the duty of candour applied.
• Medicines reviews were not consistently taking place and patients were at risk because of this.
• There were inconsistent reviews of high risk medicines and action to address risks were not always in line with national guidance. There was no system in place to deal with safety alerts.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• There was poor management of long term conditions, with patients not consistently receiving regular reviews. Performance relating to the Quality Outcomes Framework (QOF) had deteriorated since the most recent published data due to a lack of leadership and oversight.
• There were poor systems in place to keep clinical staff up to date and locum and nursing staff did not have dedicated time for clinical meetings or to complete training. GP locums had received inconsistent inductions and there was no evidence of clinical supervision.
• Patients reported there was poor continuity of care and we saw that this had a detrimental impact on the quality of patient treatment and care.
• The national GP patient survey results had further deteriorated in some areas of GP consultations since the previous inspection in April 2017.
• We observed staff to be caring and compassionate in their interactions with patients.
• Appointment systems were not working well so patients did not receive timely care when they needed it, particularly in relation to GP home visits. Patients continued to report some concerns about access to GP appointments and getting through to the practice by phone.
• Complaints were recorded and generally responded to although there was a lack of leadership, clinical oversight, investigation and learning. Action was not always taken to improve the quality of care as a result.
• 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.
• Systems relating to the requirements of the Duty of Candour were informal. Staff responsible for recording and reporting safety incidents were unaware of the requirements.
• Policies and procedures were not always accessible, clear or up to date.
• There was a good deal of uncertainty amongst staff due to unclear changes in relation to the registered provider and a subsequent impact on the staffing structure within the practice.

As a result of these findings we sent a Letter of Intent notifying the provider (Dr David Huw Jones) of our concerns and that we were considering taking action using our urgent powers to impose conditions. Ten conditions were then imposed on the provider’s registration on 18 September 2017.

The provider negotiated a termination of contract with Hastings and Rother clinical commissioning group for 31 October 2017 and is in the process of cancelling their CQC registration.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Updated 16 November 2017

The practice is rated as inadequate for the care of people with long-term conditions.

• Performance for diabetes related indicators at 92% was similar to the CCG (94%) and national (93%) averages. Unpublished data from the practice showed that current indicators were at 85%.
• Exception reporting (where patients with long term conditions are removed from QOF outcome calculations) was higher than average.

• Longer appointments and home visits were not always available when patients needed them.
• Patients did not have a named GP although we did see some evidence of personalised care planning for this group.
• Structured annual reviews were not always undertaken to check that patients’ health and care needs were being met.
• Reviews and routine tests for patients with long term conditions were not consistently being carried out.

Updated 16 November 2017

The practice is rated as inadequate for the care of families, children and young people.

• Staff did not know who the safeguarding lead within the practice was and policy information relating to this was confusing.
• Immunisation uptake rates were also relatively low for a number of the standard childhood immunisations. For example; all areas of childhood immunisations for under two year old were highlighted as negative variations in CQC data as the practice had failed to reach the 90% standard for achievement.
• The premises were suitable for this population group.

Updated 16 November 2017

The practice is rated as inadequate for the care of older people.

• The practice could not demonstrate that all staff had completed training in safeguarding adults.
• The safety of care for older patients was not a priority and there were limited attempts at measuring safe practice.
• The practice provided support to local care homes but there had been issues with telephone access, GP visits and prescription management.
• The care of older patients was not managed in a holistic way as locum GPs did not attend multi-disciplinary meetings where patient care was discussed.
• Home visits were available with a nurse practitioner for patients who were house bound, however GP home visit appointments were limited and not always responsive to need.
• The leadership of the practice had little understanding of the needs of older patients and were not attempting to improve the service for them. Services for older patients were therefore reactive, and there was a limited attempt to engage this patient group to improve the service.

Updated 16 November 2017

The practice is rated as inadequate for the care of working age people (including those recently retired and students).

• The percentage of respondents to the GP patient survey who were satisfied with the practice’s opening hours was highlighted as a negative variation in CQC data. 55% of respondents said they were satisfied compared with CCG average of 77% and the national average of 76%.
• There were no early or extended opening hours for patients who worked or students.
• There was a lower than average uptake for health screening.

Updated 16 November 2017

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

• Published data showed the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2015 to 31/03/2016) was 74%. This was below the CCG average of 86% and the national average of 89%.
• The practice had not worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.
• The practice carried out annual face to face reviews for patients with dementia, however at the time of inspection only 50% had had a review in the last year and the process for carrying out the rest was unclear.
• The practice had told patients experiencing poor mental health about support groups or voluntary organisations and a wellbeing advisor was available at Cornwallis Plaza.

Updated 16 November 2017

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

• There was little evidence of the practice working with multi-disciplinary teams in the case management of vulnerable patients.
• Not all patients identified on the learning disability register had received annual reviews. Of five patient records we reviewed we identified two patients who had never received a learning disability check and two others who had not received regular annual reviews or appropriate follow up.
• Some staff knew how to recognise signs of abuse in vulnerable adults and children, but they were not clear about who the safeguarding lead was or who to go to in case of concerns.