The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Steven Nimmo Also known as Barton Surgery Plymstock

Overall: Inadequate read more about inspection ratings

Barton, Horn Lane, Plymstock, Plymouth, Devon, PL9 9BR (01752) 407129

Provided and run by:
Dr Steven Nimmo

All Inspections

During an inspection looking at part of the service

This practice is rated as Inadequate overall.

We carried out an unannounced comprehensive inspection on the 24 October 2019 where we identified significant risks to patients. We issued the Registered Provider a Section 31 Notice of Suspension on the 29 October 2019 to suspend the provider’s registration with immediate effect as we found several breaches of regulations relating to safe, effective, responsive and well-led services. Following this inspection, we have rated this practice as inadequate overall and for all population groups.

The full report on these inspections can be found by selecting the ‘all reports’ link for Dr Steven Nimmo on our website at www.cqc.org.uk.

Following this inspection, we were made aware that the provider had handed his contract back and the practice would be closing. Had this not been the case then the practice would have been placed in special measures. Services placed in special measures would be inspected again within six months. If insufficient improvements had been made such that there remained a rating of inadequate for any population group, key question or overall, further action in line with our enforcement procedures would begin.

This inspection on the 15 November 2019 was an unannounced focused inspection. The purpose was to gather evidence on improvements made by the practice against the suspension notice, to present to a first-tier tribunal hearing, following the concerns identified at the previous inspection.

The practice was closed to patients, but we were able to talk to the Practice Manager and two staff members and review documentation. The registered manager was not present.

Concerns from the inspection on 24 October 2019 included: -

  • Safety systems, processes and standard operating procedures are not fit for purpose. The management of systems around health and safety, patient emergencies, recruitment, fire safety and infection control were not effective and unsafe.
  • The information needed to plan and deliver effective care, treatment and support was not comprehensive and some patient consultation records lacked accurate and robust notes of care and treatment.
  • Patients’ treatment and care was put at risk due to inappropriate medicines management.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients. Staff were untrained in basic life support, identifying signs of sepsis, mental capacity and safeguarding at the role-appropriate level.
  • There was limited monitoring of the outcomes of care and treatment. Performance data was significantly below local and national averages.
  • The practice had not obtained up to date Disclosure and Barring Service (DBS) checks or undertaken risk assessments for staff working in the practice.
  • Patients were not encouraged to express their views about their care and support. Complaints and concerns could not be made in accessible ways.

At this focused inspection, we found very few improvements had been made in relation to the concerns we previously identified. The improvements made were in relation to:

  • Medicines requiring refrigeration were not stored safely in the two fridges. The practice did not have assurance that the vaccines were stored at the correct temperature for them to remain effective. At this inspection we saw records that demonstrated daily checks were being made.
  • At this inspection on the 15 November 2019 we saw evidence to demonstrate that two members of staff had completed on line training for health and safety topics between the 1 November and 11 November 2019 but no other training, for example identifying signs of sepsis, had taken place. One staff member told us they had been asked to complete the training, but they had not had the time.
  • Staff files identified gaps in the recruitment system, two of the three files looked at contained no references, no employment histories or record of qualifications.
  • Disclosure and Barring Service (DBS) checks had been commenced, we saw application reference numbers alongside undated risk assessments for non-requirement. A further DBS check was dated 8 November 2019.
  • We were verbally informed by the practice manager that a new fire risk assessment had been carried out on 1 November 2019 and minor issues, for example more emergency lighting and new seals on fire doors were required.

Following this inspection, we served a further notice under Section 31 of the Health and Social Care Act 2008. This notice formally notified the provider their suspension of registration as a service provider in respect of the regulated activities has been extended from 25 November 2019 until 31 January 2020

During a routine inspection

We carried out an unannounced comprehensive inspection at Dr Steven Nimmo, (locally known as Barton Surgery) on 24 October 2019 following information received from stakeholders and a review of the information available to us.

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:

  • Safety systems, processes and standard operating procedures are not fit for purpose.
  • The management of systems around health and safety, patient emergencies, recruitment, fire safety and infection control were not effective and unsafe.
  • The information needed to plan and deliver effective care, treatment and support was not comprehensive and some patient consultation records lacked accurate and robust notes of care and treatment.
  • The practice did not have clear systems and processes to keep patients safe.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • 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.
  • The practice was unable to show that it always obtained consent to care and treatment.
  • Performance data was significantly below local and national averages.

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

  • The service does not support a caring environment and approach to people’s care, treatment and support.

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

  • Patients were frequently and consistently not able to access services in a timely way for an initial assessment, diagnosis or treatment.
  • Patients experience unacceptable waits for some services.
  • Patients were not encouraged to express their views about their care and support. Complaints and concerns could not be made in accessible ways.

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.
  • 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.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

Following this inspection, we served a notice under Section 31 of the Health and Social Care Act 2008. This notice formally notified the provider their registration as a service provider in respect of the regulated activities has been suspended from 28 October 2019 until 25 November 2019.

This notice of urgent suspension of the registration was given because we believe that a person could or may be exposed to the risk of harm if we do not take this action.

Following this inspection, we were made aware that the provider had handed his contract back and the practice would be closing. Had this not been the case then the practice would have been placed in special measures. Services placed in special measures would be inspected again within six months. If insufficient improvements had been made such that there remained a rating of inadequate for any population group, key question or overall, further action in line with our enforcement procedures would begin.

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

10 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Dr Steven Nimmo (Barton Surgery) on 10 October 2017. Overall the practice is rated as good.

We carried out an announced comprehensive inspection at Barton Surgery on 8 December 2015. At this inspection the overall rating for the practice was requires improvement. The domains of effective, caring and well led were rated as requires improvement. The domains of safe and responsive were rated as good.

We then carried out an announced focused follow up inspection on 6 September 2016. This was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations from the previous inspection in December 2015. We focused on the three domains which had been found to require improvement; effective, caring and well led. At that inspection the overall rating for the practice was good. The three domains of effective, caring and well led were rated as good.

We carried out this inspection on 10 October 2017 as an announced focused follow up inspection to establish whether changes seen in 2016 were embedded within the practice. This report covers our findings and any additional improvements made since our last inspection.

The reports on these inspections can be found by selecting the ‘all reports’ link for Dr Steven Nimmo (Barton Surgery) on our website at www.cqc.org.uk.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • 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 with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

6 September 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an inspection at Dr Steven Nimmo (known as Barton Surgery) on the 6 September 2016. This inspection was performed to check on the progress of actions taken following an inspection we made in December 2015. Following the inspection in December 2015 the provider sent us an action plan which detailed the steps they would take to meet their breaches of regulation. During our latest inspection on 7 September 2016 we found the provider had made the necessary improvements in delivering effective, caring and well led services.

This report covers our findings in relation to the requirements and should be read in conjunction with the comprehensive inspection report published in March 2016. This can be done by selecting the 'all reports' link for Dr Steven Nimmo on our website at www.cqc.org.uk

Our key findings across the areas we inspected in this focused follow up inspection were as follows:

  • The practice had improved their service through the introduction of a structured approach to the reporting and recording of significant events and complaints. This included regular meetings and shared learning to address these.
  • Risks to patients were assessed and well managed.
  • Clinical audits were being undertaken and demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. The practice now had an overview of training which specified what training staff had received or required.
  • Systems were in place to obtain consent for treatment. Joint injection examples provided evidence of recorded verbal consent.
  • Emergency equipment was in place, was easily accessible and was checked on a regular basis.
  • The practice had improved their provision of caring services through an analysis of the GP Patient Survey results from July 2015 to July 2016 and the identification of required improvements. Survey results were now in line with CCG and national averages.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had a new recruitment procedure in line with current guidance. We saw evidence of complete staff files including a new member of staff. Staff were only recruited following a thorough recruitment process.
  • A set of policies and procedures had been made available to staff, including a staff handbook.
  • Patient feedback was sought and acted upon.
  • Staff feedback had also been sought and acted upon. Staff we spoke with told us they felt listened to and their suggestions had been acted upon.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Steven Nimmo (Known as Barton Surgery) on Tuesday 8 December 2015. We had previously inspected the practice in April 2015 when we found serious concerns. As a result the practice was rated as inadequate and put into special measures. Following the inspection the practice sent us an action plan of how they were going to address the issues. The practice has made significant improvements in relation to safety; they are continuing improve their effectiveness, responsiveness and leadership. At this inspection we have rated the practice as overall requiring improvement.

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

  • There had been improvements since the last inspection. However, the approach to service delivery and improvement continued to be reactive and focused on short term issues. Further improvements were not always identified.
  • There was a more structured approach to the reporting of and recording of significant events and complaints.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There had been improvements in the recruitment procedure. Staff were only recruited following a robust recruitment process.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Clinical areas had been tidied and reorganised. Infection control audits had now taken place.
  • Information about services and how to complain continued to be available and easy to understand.
  • A set of policies and procedures had been made available to staff, these were being developed further.
  • Patients said they found it easy to make an appointment with a GP, although they had to wait longer to see the GP of their choice. Patients also said urgent appointments were available the same day.
  • Processes were in place for maintaining clinical equipment, although some emergency equipment was not in place, but was sourced by the next day.
  • Patient feedback was sought and acted upon.
  • Staff had access to whistleblowing policies, had attended safeguarding training and the practice had advertised chaperoning services.
  • Checks had been introduced to ensure fridge temperatures and emergency equipment were checked.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are to:

  • Introduce systems to show that consent is obtained and, where appropriate, recorded in line with relevant guidance and legislation and includes details of risks prior to minor surgery and invasive procedures, including excisions being performed.

  • Ensure the governance and audit systems are proactive and focussed on improvement and used to identify issues and drive improvements.

The areas where the provider should make improvement are:

  • Introduce a system to maintain an overview of significant events and complaints which could be used to and identify and monitor any trends.

  • Demonstrate that the remaining patient group directive has been fully adopted by the GP provider to allow nurses to administer the shingles vaccine in line with legislation.

  • Introduce systems to ensure the strategic plan is kept under review to ensure it contained up to date details of partners.

  • Act upon the national patient GP survey results published in July 2015.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Steven Nimmo (Barton Surgery) on Wednesday 29 April 2015.

Overall the practice is rated as inadequate.

Specifically, we found the practice to be good for providing caring services, requires improvement for effective and responsive services and inadequate in providing safe and well led services. Whilst patients were received a caring service the shortfalls in some aspects of safety, and the lack of communication, leadership, and quality monitoring have meant that the ratings for the population groups are also inadequate.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Although the practice carried out investigations when things went wrong, the process followed was not systematic and did not always follow the practice policy. The lessons learnt were not always documented or communicated to all staff and so safety was not improved.
  • Clinical risks to patients were assessed and well managed.
  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.
  • Infection control procedures did not protect patients from risk. There had not been an infection control audit performed at the practice in the last five years
  • Data showed patient outcomes were average for the locality. Although some clinical audits had been carried out, evidence did not always show that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Staff worked with multidisciplinary teams although this was on an informal basis as and when the GP needed to discuss individual patients with health care professionals.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
  • The practice had a number of policies and procedures to govern activity, but these were over five years old and had not been reviewed since.
  • The practice did not hold systematic governance meetings. Issues were discussed when an issue happened.
  • The practice did not proactively seek feedback from staff or patients.

There were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve:

  • There must be proper and safe management of medicines including: consistent monitoring and recording fridge temperatures on a daily basis; keeping medicines policies under review, ensuring all patient group directives are signed by the staff using them, and ensuring staff are aware of and follow the system to record when blank prescription printer forms are taken from the secure storage to GP consulting rooms to show the whereabouts of these forms.
  • Assess the risk and prevent, detect and control the spread of infections, including those that are health care associated by ensuring comprehensive infection control guidance and policies are available for staff, and by auditing infection control to assess the risks and to demonstrate they are mitigating any such risks where reasonably practicable.
  • Ensure that systems are in place to ensure the equipment used by the service provider for providing care or treatment to a patient is safe for such use and is used in a safe way:

- A system must be in place to ensure all clinical equipment is checked and portable appliance testing carried out (PAT) where appropriate.

-Introduce records to confirm the emergency equipment is checked regularly.

- Emergency equipment must also be checked regularly to ensure it is ready for use in an emergency.

  • Establish and operate recruitment procedures to ensure that all required information regarding pre-employment checks is recorded and kept.
  • Establish systems or processes to assess, monitor and improve the quality and safety of the services provided.
  • Perform an annual or more frequent patient survey to ascertain experience of patients.
  • Ensure that significant events and complaints are effectively managed and recorded. Identify any trends and risks to patients and demonstrate learning and action taken. Review all policies and procedures annually or more frequently to enable staff to have up to date and current guidance to follow.

Action the provider SHOULD take to improve:

  • Ensure patients are aware of the chaperone service.
  • Consider having regular scheduled meetings with staff at the practice and the multidisciplinary team to discuss vulnerable patients and end of life care patients.
  • Ensure all staff have an awareness of their roles in relation to the Mental Capacity Act (MCA).
  • Consider ways of improving communication amongst staff.

I am placing the service into 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 vary the provider’s registration 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

29 September 2014

During an inspection looking at part of the service

We carried out this inspection in order to follow up on non-compliance we had identified at the scheduled inspection carried out in September 2013. The non-compliance related to supporting staff and staff training at the practice.

We did not speak with any patients on this occasion.

During this inspection of 29 September 2014, we found that significant improvements had been made relating to supporting staff and training and were continuing with these changes.

The practice had responded to the findings of the previous CQC inspection report and had taken action to successfully achieve compliance.

19 September 2013

During a routine inspection

We spoke with seven people who used this service. Overall we received good feedback about the staff. Comments included "urgent response with children [very good]", and "new forward looking [GPs]". People said they were treated with dignity and respect by staff, and they felt involved in their treatments because options were discussed with them.

Four people expressed dissatisfaction with the appointment system and availability of appointments. They also described long waiting times after their appointment time to see their GP.

We spoke with six staff. None had attended safeguarding training and none was planned. They were however confident about what to do, and we saw evidence of appropriate action that had been taken about a safeguarding concern.

There were not robust training arrangements in place. Clinical staff were responsible for their own training to meet their roles and registration requirements. We found there was no system to identify training staff had completed or that would need to be refreshed on an annual basis, for example, infection control. Only the provider had completed safeguarding vulnerable adults training. All the GPs had completed child protection training. The non clinical staff were not provided with an opportunity to discuss their work, any training needs, and their professional development.

There were systems in place to monitor the quality of the service provided and patients were able to give feedback about the service they received.