Archived: Parkview Surgery

We carried out an announced focused inspection at Parkview Surgery on 16 and 19 December 2022. Overall, the practice is rated as inadequate.

After the inspection, on 22 December 2022, we issued enforcement warning notices for Regulation 12 – Safe care and treatment and Regulation 17 – Good governance. The practice has been given a timeframe to comply with the warning notices. Further details can be found at the end of this report under enforcement actions.

Safe - Inadequate

Effective – Requires Improvement

Caring – Not Inspected

Responsive – Not Inspected

Well-led - Inadequate

Why we carried out this inspection

This announced focused inspection was carried out as a result of some information of concern we received in relation to systems and processes to ensure safe and effective care and treatment.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter site visit.
• Reviewing staff questionnaires.
• Staff interviews.

Our findings

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:

• There were gaps in safeguarding systems and processes.
• Recruitment checks were not always carried out in accordance with regulations.
• A record of the vaccination status of all staff was not maintained in line with guidance.
• The practice had not undertaken any risk assessments of their own practice area, which included health and safety.
• The practice did not have a system in place to monitor the facilities management undertaken by NHS Property Services on an ongoing basis to satisfy themselves that all areas were compliant.
• Aspects of medicines management which included the management of patients prescribed some high-risk medicines, medicines reviews and medicines usage were not always effective.
• Blank prescription forms for use in printers were not recorded and tracked through the practice.
• There was no consistent system in place to ensure the appropriate authorisations to administer medicines by the healthcare assistant under a Patient Specific Direction.
• Systems and processes to report, share, investigate, record, respond and learn from incidents, critical incidents/near misses were not always consistent and effective.
• Systems for managing and acting on patient safety alerts were not always effective.

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

• The management of patients with some long-term conditions was not always in line with guidance.
• The practice was unable to demonstrate that all staff, including locum staff, had received the appropriate training, supervision and appraisal.
• The practice was unable to demonstrate an effective induction system for all staff, including locum staff.

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

• There was a lack of systems and processes established and operated effectively to ensure compliance with the requirements to demonstrate good governance which included the management of incidents and patient safety alerts.
• There was no structured and effective system to communicate and document safety and quality outcomes to keep all staff, including locum staff, informed.
• Systems and processes to manage clinical correspondence, patient related tasks and referrals were not effective and impacted on accurate, complete and contemporaneous patient records.

We found breaches of regulations. 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.
• Ensure all premises and equipment used by the service provider is fit for use.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• 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.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for 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 6 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 6 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.

The evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services