Archived: Hastings Old Town Surgery

We carried out an announced comprehensive inspection at Hastings Old Town Surgery on 22 July 2019.

This inspection was to follow up on breaches of regulations and as part of our schedule of inspections where services placed in special measures will be inspected again within six months. At this inspection we followed up on breaches of regulations identified at a previous inspection on 7 November 2018. The November 2018 inspection was a comprehensive inspection following an unannounced focused inspection on 3 October 2018 in response to concerns. Breaches of regulations identified included breaches to regulation 12 (safe care and treatment), regulation 17 (good governance), regulation 18 (staffing) and regulation 19 (fit and proper persons employed).

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 appropriate systems in place for the safe management of medicines.
• The practice did not consistently learn and make improvements when things went wrong.
• There were systems to assess, monitor and manage risks to patient safety, however staff were not consistently aware of how to use emergency equipment, particularly in relation to the administration of oxygen to a patient who was not breathing.
• Staff did not have the information they needed to deliver safe care and treatment due to a backlog in administrative work.

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

• While the practice had made some improvements since our inspection on 7 November 2018, it had not appropriately addressed issues in relation to the monitoring of patients on high risk medicines.
• 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 with sufficient focus on quality improvement.
• 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 always act on appropriate and accurate information.
• There was evidence of some systems and processes for learning, continuous improvement and innovation, however there was insufficient clinical and leadership oversight of improvement activities and not all aspects of learning were considered.

We rated the practice as requires Improvement for providing effective services because:

• Clinical audits and improvement activities were not always timely, including where there was significant risk to patients, and there was insufficient leadership and clinical oversight of these processes.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles, in particular in relation to non-medical prescribing practice.
• There was limited monitoring of the outcomes of care and treatment, in particular in relation to childhood immunisations and antibiotic prescribing.
• Two week wait referrals were not sufficiently monitored or followed up and there was no system to check and record results.

These areas affected all population groups in effective, so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive 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 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 exception reporting in areas where it is higher than average.
• Review antibiotic prescribing with a view to improving in line with national usage.
• Improve the proportion of adults with newly diagnosed cardio-vascular disease who are offered statins.
• Review the uptake of cervical screening with a view to making improvements.

This service was placed in special measures in February 2019. Insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall. Therefore, we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration’

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

This practice is rated as inadequate

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection on 7 November 2018 as part of our inspection programme. Prior to this we carried out an unannounced focused inspection on 3 October 2018 in response to concerns that were reported to us. Hastings Old Town Surgery was originally inspected following a change in ownership of the practice in 2017.

At this inspection we found:

• The practice did not have a clear system in place to track significant events nor learn from these.

• Arrangements for the security of prescription forms was not sufficient.

• A fire door was found to be held open at the practice.

• Actions taken in response to specific risk assessments were not clear.

• Pre-employment checks undertaken by the practice were not thorough.

• Medicine reviews were not being recorded effectively.

• The practice’s overarching governance framework was not effective and did not support the practice to identify and act upon areas for improvement.

• The lack of leadership and oversight in the practice resulted in ineffective systems to identify and proactively manage risks, issues and performance.

• Appraisals for all staff had not been completed.

• The practice did not have a functioning patient participation group.

• The practice had been recognised by the local clinical commissioning group for their success in using care navigation.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they could access care when they needed it.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

• Establish and operate effectively a system for identifying, receiving, recording, handling and responding to complaints.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Ensure that staff receive appropriate support, training professional development, supervision and appraisal as is necessary to carry out the duties they are employed to perform.

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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 FRCGP) 

Chief Inspector of General Practice

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services well-led? - Inadequate

Hastings Old Town Surgery was last inspected on 8 December 2016 and was found to be good in all of the key questions. This inspection was an unannounced focused inspection and was carried out on 3 October 2018 in response to concerns that were reported to us. A CQC medicines manager visited the practice on 8 October 2018 to review the management of medicines.

The inspection focused on the key questions – are services safe and well-led.

At this inspection we found:

• The practice did not have a clear system in place to track significant events nor learn from these.

• Pre-employment checks undertaken by the practice were not thorough.

• Arrangements for the tracking and security of prescription forms was not sufficient.

• Fire doors were were found to be propped open within the practice.

• 37% of patients who required a medication review had not had one done between October 2017 and October 2018.

• Test results for 495 patients were found to be outstanding, 221 of which had been flagged as abnormal.

• The practice held incomplete records of the temperature of the medicines fridge.

• Complaint response letters written to patients had not been dated and the complaints policy was not followed appropriately.

• The practice did not have a functioning patient participation group.

• The practice’s overarching governance framework was not effective and did not support the practice to identify and act upon areas for improvement.

• The lack of leadership and oversight in the practice resulted in ineffective systems to identify and proactively manage risks, issues and performance.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.

• Establish and operate effectively a system for identifying, receiving, recording, handling and responding to complaints.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Ensure that staff receive appropriate support, training professional development, supervision and appraisal as is necessary to carry out the duties they are employed to perform.

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice