The Care Quality Commission
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Archived: Caxton House Surgery

Overall: Requires improvement read more about inspection ratings

53 High Street, Grimethorpe, Barnsley, South Yorkshire, S72 7BB (01226) 711228

Provided and run by:
Dr Saxena

All Inspections

16 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at Caxton House Surgery on 10 October 2018 and the practice was rated as inadequate and enforcement action taken against the provider.   We carried out a further inspection on 28 February 2019 and whilst some improvement was seen, the practice was rated as inadequate and placed into special measures.

A focused inspection took place on 20 August 2019 to check compliance with the warning notice issued in March 2019 for a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17, Good governance.

At the February 2019 inspection we rated the practice as inadequate for providing safe, effective and well-led services and requires improvement for responsive services because:

  • T There were concerns in relation to the lack of documentation in the patient records and regular prescribing of some medicines and there were gaps in systems to assess, monitor and manage risks to patient safety.
  • There was limited monitoring of the outcomes of care and treatment for those whose circumstances may make them vulnerable and those people experiencing poor mental health.
  • The practice did not have a planned programme of learning and development.
  • The practice did not have clear and effective processes for managing risks and lacked a clear vision that was supported by a credible strategy.
  • The practice organised and delivered services to meet patients’ needs. However, appointments were not available before 9am and there was no clinical cover during this time.

At this comprehensive inspection we followed up a practice in special measures and on breaches of regulations identified at the previous inspection in February 2019.

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 Requires improvement overall.

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

  • T The practice had reviewed systems and processes to assess, monitor and manage risks to patient safety.
  • Disclosure and barring (DBS) checks had been undertaken for relevant staff.

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

  • The practice had reviewed how they monitor those who circumstances may make them vulnerable and those experiencing poor mental health. Joint clinics with other services were now held in the practice. Audits had been performed, however improvement in the overall outcomes for hypnotic prescribing and some cancer screening was yet to be demonstrated in the national figures as the changes needed to be embedded into practice.
  • From the records we reviewed care and treatment was documented in line with current legislation, standards and evidenced based guidance.
  • Staff had undertaken statutory and mandatory training.

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

  • Appointments were now available to patients from 8.30am and there was clinical cover at the practice from this time.
  • The premises at Grimethorpe had been refurbished.

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

  • The provider had introduced processes for managing risks and issues. However a fire risk assessment had not been completed at the main surgery and branch premises.
  • The provider had reviewed the governance processes to ensure continuous learning and improvement.
  • Initiatives introduced to improve patient care had not yet been reflected in the practice achievement outcomes. The practice did not routinely monitor Public Health England screening figures to demonstrate improvement.

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:

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

I am taking this service out of special measures. This recognises the improvements made to the quality of care  provided by this service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

20 August 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Caxton House on 28 February 2019 and the practice was rated as inadequate overall and placed into special measures.

This focused inspection was to check compliance with the warning notice issued in March 2019 for a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17, Good governance.  As this inspection was to check compliance with the warning notice, the ratings from the previous inspection in February 2019 have not been changed.

During our inspection on 28 February 2019, we found that the governance arrangements were ineffective and arrangements to improve them were reactive, addressing issues as they arose.

This was because:

  • The practice did not have any formal business plans and no evidence of succession planning for the future.
  • Risk assessments did not always identify all the issues present in the practice.
  • Recruitment records for GP locums who worked at the practice were not kept.
  • An accurate, complete and contemporaneous record in respect of each service user was not always kept.

We based our findings from this inspection on 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

At this inspection we found that arrangements relating to the warning notice for good governance had been met. 

We found that:

  • The provider had a business plan in place that identified succession planning for the future.
  • The practice had reviewed the risk assessments undertaken and updated them to accurately reflect the findings.  Risk assessment due dates were all now recorded in an electronic calendar which prompted staff when they were due for review.  Actions taken were documented within the risk assessment.
  • Appropriate recruitment and training records were kept.
  • Staff had undertaken further training in the patient record system and shared care records were now visible and patient reviews had been undertaken and documented.

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

28 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Caxton House on 28 February 2019.

At this inspection we followed up actions taken by the provider following Regulatory Action at a previous inspection on 10 October 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:

  • While the practice had made some improvements since our inspection on 10 October 2018, it had not appropriately addressed the concerns in relation to the lack of documentation in the patient records and regular prescribing of some medicines and there were gaps in systems to assess, monitor and manage risks to patient safety.
  • Recruitment and DBS checks were not carried out in accordance with the regulations for GP locum staff directly employed by the practice.
  • There was limited monitoring of the outcomes of care and treatment delivered to patients.

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

  • While the practice had made some improvements since our inspection on 10 October 2018, there was limited monitoring of the outcomes of care and treatment for those whose circumstances may make them vulnerable and those people experiencing poor mental health.
  • Staff told us patients’ needs were assessed, however care and treatment was not documented in line with current legislation, standards and evidence-based guidance and supported by clear pathways and tools.
  • The practice did not have a planned programme of learning and development.

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

  • While the practice had made some improvements since our inspection on 10 October 2018, it had not appropriately addressed the concerns in relation to the lack of insight to manage a range of risks to drive improvement .
  • 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 did not have clear and effective processes for managing risks and issues.
  • 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 good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

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

  • The practice organised and delivered services to meet patients’ needs. However, appointments were not available before 9am and there was no clinical cover during this time.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure all premises and equipment used by the service provider is fit for use and appropriate standards of hygiene maintained.
  • 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).

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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

10 October 2018

During a routine inspection

This practice is rated as inadequate overall.  (Previous rating July 2016 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We initially inspected Caxton House on 9 December 2014. The practice was rated as inadequate due to failures to comply with Regulation 12 Safe care and treatment, Regulation 13 Safeguarding, Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance and Regulation 19 Fit and proper persons employed.  Requirement notices were issued and the practice was placed in special measures. 

A second inspection took place on 3 November 2015 and the practice was rated as requires improvement overall. Failure to comply with Regulations 16 Receiving and acting on complaints, Regulation  17 Good governance and  Regulation  18 staffing were found and requirement notices issued.  The practice was removed from special measures following this inspection. A further inspection took place on 12 July 2016 of safe, responsive and well-led to review the requirement notices which were met during this time. The practice was then rated as good overall and for all population groups.

We carried out an announced inspection Caxton House on 10 October 2018 as part of our inspection programme.

At this inspection we found:

  • The provider lacked understanding and insight into the responsibilities required to run a general practice. There was a lack of insight to manage a range of risks and to drive improvement over the longer  term .  This continues to be reflective throughout all inspections over a period of time.
  • The arrangements to ensure that facilities and equipment were safe and in good working order were unsafe. For example, a health and safety risk assessment at the Grimethorpe site had not been completed and there were areas that had the potential to cause injury. CQC received evidence following the inspection that a risk assessment of the Grimethorpe premises had been completed on 15 October 2018.
  • Systems to assess, monitor and manage risks to patient safety were not adequate. Three staff, including the GP, worked at the practice. Arrangements were in place to cover the GP if they took leave but not for other members of staff who had oversight and performed all of the administrative duties within the practice.
  • Due to the lack of documentation in the patient record we could not be confident that patients’ immediate and ongoing needs were fully assessed. For example, lack of suicide or self harm risk assessments for those patients with poor mental health
  • Investigations into incidents were not reviewed by a clinician independent to the event and reports lacked detailed investigations and further learning.
  • Patients told us they were treated with dignity and respect and found it easy to make appointments at the practice.

The areas where the provider must  make improvements are:

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

  • 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:

  • Review the caring responsibilities of patients to capture those who may require further support. The practice needs to establish what services are available to carers' in the area and actively promote them.
  • Review the provision of GP appointments before 10am in the morning.

Information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals h ave been concluded.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

12 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 3 November 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance and Regulation 18 Staffing.

We undertook this focused inspection on 12 July 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Caxton House on our website at www.cqc.org.uk.

Overall the practice is rated as Good.

Specifically, following the focused inspection we found the practice to be good for providing safe, responsive and well-led services. Our key findings across all the areas we inspected were as follows:

  • The practice reviewed learning from complaints, incidents and safety alerts to influence a programme of continual quality improvement.
  • The practice reviewed how they monitored risks which now included a GP lone worker risk assessment.
  • The actions from the infection prevention and control audit had been followed up and improvements to the building were still on-going.

  • A number of policies and procedures to govern activity had been introduced. We were told complaints and incidents were discussed and reviewed in practice meetings to enable staff to learn from experiences and reduce future risk. The practice had started to identify common themes from complaints, incidents and feedback from patients to contribute to a programme of continuous quality improvement.

rofessor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a follow up inspection on 3 November 2015 at Caxton House Surgery. The practice was placed in special measures due to non-compliance with the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 following our previous inspection in December 2014.

During this inspection, we found the practice had made some improvements since our last inspection and they were meeting three of the five regulations which had previously been breached. However the provider is in breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 16 Receiving and acting on complaints, Regulation 17 Good Governance and Regulation 18 Staffing.

The ratings for the practice have been updated to reflect our findings. We found the practice and to require improvement in areas relating to safe, responsive and well-led. The practice was good at being effective and caring for patients.

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. The practice had implemented a new system to record and monitor information about safety which was appropriately reviewed and addressed.
  • The practice had more recently reviewed how they monitored risks to patients. Some risks were now assessed and managed. The practice did not have a GP lone worker risk assessment and the actions from the infection prevention and control audit were yet to be completed.
  • The Quality and Outcomes Framework showed patient outcomes were above average for the locality.
  • Some audits had been carried out and we saw some evidence audits were driving improvement in performance to improve patient outcomes. The practice did not have a programme of continuous quality improvement.
  • 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 reviewed its complaints process. Complaint investigation records did not detail all of the investigatory process and the actions taken.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had more recently, in September and October 2015, developed a number of policies and procedures to govern activity.
  • The practice did not hold governance meetings and issues were discussed at monthly staff meetings.
  • The GP took the lead for most areas supported by the senior receptionist. We have concerns relating to the sustainability of this working arrangement with the lack of practice nursing and practice management support.

The areas where the provider must make improvements are:

  • Ensure when dealing with complaints the process follows the Parliamentary and Health Service Ombudsman ‘Principles of Good Complaint Handling’ guidance.

  • Ensure a programme of continuous quality improvement is developed to monitor quality and to make improvements, particularly learning from incidents, safety alerts and complaints.

  • Ensure a GP lone worker risk assessment is completed and action taken in accordance with the findings

In addition the provider should:

  • Implement the actions identified in the infection prevention and control audit in accordance with the findings.

  • Review and implement guidance from NHS Protect Security of Prescription Forms.

  • Review arrangements for documenting actions taken as a result of best practice guidance and patient safety alerts.

  • Review the provision of child oxygen masks.

  • Review the time patients wait for an appointment in the surgery.

  • Develop a practice information pack for locums.

  • Review the provision of morning appointments before 11am.

I confirm that this practice has improved sufficiently to be rated ‘Requires improvement’ overall. The practice will be removed from special measures.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

9 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected Caxton House on the 9 December 2014. We inspected this practice as part of our comprehensive, inspection programme. We looked at how well the practice provided services for specific groups of patients. These included; older patients, patients with long-term conditions, families, children and young people, working age patients (including those recently retired and students), patients living in vulnerable circumstances and patients experiencing poor mental health (including people with dementia). The overall rating for this practice was inadequate.

Our key findings were as follows:

  • Patients were very complimentary about the GPs, the reception staff and the care and treatment they received. They said they could usually get an appointment when they wanted one.
  • Patients said they received care and treatment appropriate to their needs. They said they felt the GP took time to explain their diagnosis or condition and felt involved in decisions about their treatment.
  • Patients said they felt the practice offered a very good service and staff were helpful and caring. They said staff treated them with courtesy and respect.
  • One of the GPs visited the local care home every week to review patients and carry out any scheduled health checks.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must ensure that:

  • staff are aware of and follow adult and children safeguarding policies and procedures and complete role specific safeguarding training.
  • staff are aware of and follow infection control policies and procedures.
  • legally required checks are carried out before new staff are appointed.
  • staff receive annual CPR training.
  • patients can access copies of the practice’s complaints procedure which must be in accordance with the NHS England Standard General Medical Services contractual requirements and comply with the requirements of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
  • arrangements are put in place for identifying, recording and managing risks of inappropriate or unsafe care and treatment.
  • arrangements are put in place to regularly assess and monitor the quality of the services provided.
  • fire safety equipment is checked and marked to show when servicing or replacement is required.

In addition the provider should ensure that:

  • clinical audit cycles are fully completed and used to evidence improvements in patient care and outcomes.
  • the risks of contamination of the water supply are assessed and arrangements put in place for the management, testing and investigation of legionella.
  • staff learning and development needs are assessments and individual training plans put in place.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice