The Care Quality Commission
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Archived: Waterbeach Surgery

Overall: Inadequate read more about inspection ratings

Rosalind Franklin House, Bannold Road, Waterbeach, Cambridge, Cambridgeshire, CB25 9LQ

Provided and run by:
Dr Ranam Al Ghazzi

Important: The provider of this service changed. See new profile

All Inspections

28 October 2020

During a routine inspection

We carried out an announced comprehensive inspection at Waterbeach Surgery on 28 October 2020. We rated this service as inadequate, overall. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.

At the previous comprehensive inspection published January 2020, the practice was rated as inadequate overall with a rating of inadequate in providing safe, effective and well led services. The practice was rated as requires improvement for caring and responsive services. As a result of the concerns identified the provider was suspended from November 2019 to May 2020. Following this suspension, conditions were imposed on the registration of the practice with the CQC. The practice was put into special measures.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information the practice sent to us prior to the inspection
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews and review documents sent by the provider from 29 September 2020 and carried out a site visit on 28 October 2020.

We noted, whilst their registration was suspended (November 2019 to April 2020) and a different support agency from the current GP Federation was in place, the provider was on extended leave from November 2019 to March 2020. The provider returned in March 2020 and engaged in driving the improvements needed to address the concerns identified in our inspection November 2019.

At this inspection, the practice was rated as requires improvement for providing safe services because:

We found improvements had been made, however, most of these had only been made and implemented since March 2020 and needed further improvement, embedding and evidence that they would be sustained. We noted, whilst their registration was suspended and a different support agency from the GP Federation was in place, the provider had from November 2019 to March 2020 a period of extended leave.

  • We found that the practice system and process to ensure all significant events were reported, investigated and appropriate actions taken in a timely manner had failed. We found a significant event had been delayed and the shared learning and implementing changes put other patients at risk.
  • There were improvements in the practice oversight of training, however we found the practice did not evidence that all staff had completed the training the practice deemed mandatory. Staff we spoke with were knowledgeable in the areas where evidence had not been provided.

At this inspection we have rated all population groups as inadequate and therefore the practice rating for providing effective services is inadequate. The practice was rated as inadequate for providing effective services because:

The practice performance for QOF 2019/2020 indicators which could affect all population groups was significantly below the Clinical Commissioning Group (Clinical Commissioning Group) and national averages. In most areas the practice performance was lower than at our previous inspection. The practice was aware of this and following our previous inspection had invested clinical time into reviewing the practice processes. This included exception reporting and skill mix. However, we found the practice was experiencing a significant lack of employed clinical staff. This shortage was challenging them to ensure all patients were receiving monitoring and review within a timely manner. They shared with us a written plan to address these shortfalls, but these plans were reliant on the successful employment and retention of new staff. They shared with us a written plan to address these shortfalls, but these plans were reliant on the successful employment and retention of new staff. On the day of the inspection the practice told us some of the vacant posts had been filled although the new staff members employed had not yet started working at the practice.

  • We found the practice did not have wholly effective systems in place to ensure staff felt fully supported or supervised to feel confident they were delivering safe and effective services.
  • The practice review of coding and summarising of medical records had been implemented and the practice had achieved 58% of all records reviewed. This was is in line with the practice action plan. However, as over 42% of the records had not been reviewed, we cannot be assured that patients had received care and monitoring appropriately and in a timely manner.

At this inspection, the practice was rated as good for providing caring services.:

At this inspection, the practice was rated as inadequate for providing responsive services because:

  • Data from the GP Patient Survey 1 January 2020 to 31 March 2020 showed patient satisfaction was significantly lower than the data from the GP patient Survey 1 January 2019 to 31 March 2019. The data was below the CCG and national average. Patient and feedback to CQC was mixed in the feedback with themes of low satisfaction of access despite the practice installing a new telephone system.

At this inspection, the practice was rated as inadequate for providing well led services because:

  • The practice had been supported by the CCG since the last inspection and by a GP Federation since March 2020. As a result of this significant investment of additional clinical and management support improvements had been seen. However, at our last inspection, we had identified significant risks to patients and there were still further improvements to be made, and further analysis of unmet need to be undertaken. The improvements made required to be fully embedded and sustained.
  • We found improvements in the governance and management oversight of risks to patients and staff had significantly improved, but some needed to be further improved, embedded and sustained.
  • We found the performance of the practice QOF 2019/2020 (this was performance data before the challenges of Covid-19) was significantly lower than QOF 2018/2019 as in our last report. This did not give assurance that patients had received structured reviews in a timely manner.
  • Staff were mixed in their feedback about the practice and the leadership. The practice had made significant changes to staff employment and support and not all staff had found this easy. There had been poor staff retention and on the day of the inspection, the provider was the only GP permanently employed at the practice.
  • Patient’s feedback was mixed with positive comments about the changes and the improved leadership. The results of the 2020 GP patient survey were significantly lower than the results of the 2019 GP Patient Survey.

The areas where the provider must make improvements are:

  • Maintain, embed and sustain effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The areas where the provider should make improvements are:

  • Continue to monitor the carers list and continue to find ways to identify patients who are carers to ensure they receive care and support.
  • Continue to monitor the carers list and continue to find ways to identify patients who are carers to ensure they receive care and support.
  • Continue to monitor feedback from patients including the GP patient survey to improve patient satisfaction.

This service was placed in special measures in January 2020. Some improvements have been made, however insufficient improvements have been made in some areas. Therefore, the service will remain in special measures for a further six months. 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 act in line with our enforcement procedures to begin the process of preventing the provider from operating the service.

Special measures will give people who use the service the reassurance that the care they get should improve.

As a result of the findings from our inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue a notice of decision to vary the conditions and impose new conditions on the provider’s CQC registration. For further information see the enforcement section of this report.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

7 Nov 2019

During a routine inspection

This practice is rated as Inadequate overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Waterbeach Surgery on 7 November 2019 as part of our inspection programme.

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 concluded that:

  • People were not adequately protected from avoidable harm.
  • The leadership, governance and culture of the practice did not assure the delivery of high quality care.
  • Some legal requirements were not met.

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

  • We found the practice’s systems, processes and practices for safeguarding patients were inconsistent. In addition to this, the practice told us they did not hold multi-disciplinary team meetings with other services. The practice did not evidence any other means for sharing information with other health professionals.
  • The practice did not provide evidence they had oversight of all staff vaccinations in line with current Public Health England guidance.
  • We found that fire and health and safety risk assessments had not been completed for the practice premises. In addition to this, we found potential hazards relating to fire safety and health and safety on the day of the inspection.
  • The practice manager had completed an infection control audit prior to the inspection in September 2019 and had identified a number of risks but no actions had been taken. In addition to this, we found additional areas of potential infection control risks on the day of the inspection.
  • The practice’s coding of medical records did not support safe care for patients. The practice coded patients records as having care plans completed. However, when we reviewed patient records we found that no documented care plans had been recorded on any of the records we reviewed. In addition to this, the practice did not code medicine reviews on the patient record system and therefore could not demonstrate how people received structured review of their medicines to determine it remained safe and effective to continue with them.
  • The practice did not have a system in place for monitoring urgent and non-urgent cancer referrals.
  • The practice did not have a system in place to manage patient safety alerts.
  • The practice had higher levels of antibiotic prescribing compared with CCG and England averages. The practice reviewed the financial impact of this, and had completed a CCG-led audit, but no actions had been taken to try and improve the prescribing rate and improve patient outcomes.

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

  • We found a number of examples where clinical coding was missing from patient records or the clinical coding applied was not accurate.
  • The practice’s Quality Outcomes Framework (QOF) performance for some long-term and mental health indicators were below CCG and England averages. The practice did not have any plans in place to improve this at the time of the inspection.
  • The practice’s data showed that 81.3% of patients diagnosed with dementia and 67.6% of patients with schizophrenia, bipolar affective disorder and other psychoses had a care plan. However, we found that care plans were not documented on the practice’s patient record system for any patients that we reviewed and the practice told us these were only completed verbally.
  • The practice’s uptake of cervical screening was below the 80% target rate; the practice were aware of this data but had no plan in place at the time of inspection to improve it.
  • The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 6 months of the date of diagnosis was below the CCG and England averages. The practice were aware of this data but had no plan in place at the time of inspection to improve it.
  • The practice had completed 10 health checks for patients diagnosed with a learning disability, out of 22 eligible patients (45%). The practice were aware of this data but had no plan in place at the time of inspection to improve it.
  • We found that the practice did not have a quality improvement program in place to monitor and improve the quality of care provided to patients.

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

  • The practice manager and lead GP told us the practice did not have a carers register and were unable to tell us how many carers the practice had identified. However, during the inspection an administrative member of staff informed us there were 53 (approximately 0.9% of the practice population) patients coded as carers. The accuracy of the coding of these patients was not known.
  • A treatment room did not have any signage on the door advising of its use, nor did it have anything to suggest if it was occupied or free. The treatment room did not have a curtain and therefore did not ensure privacy.

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

  • Patient feedback through the NHS Choices and feedback on the day of the inspection was negative in relation to accessing the practice. Feedback through the National GP Patient Survey were generally in line with CCG and England averages, however some indicators were below. The practice were aware of this feedback but had taken no actions to improve patient satisfaction.
  • The practice did not record verbal complaints and they told us they did not analyse trends of complaints. The practice therefore missed the opportunity to identify themes and take action as required.

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

  • We found a lack of leadership capacity and capability with no succession plan, vision or strategy to provide high quality sustainable care.
  • We found the governance systems and management oversight did not ensure that services were safe or that the quality of those services was effectively managed.
  • The practice could not evidence that risks, issues and performance were managed.
  • The practice had not acted upon negative feedback from patients regarding accessing the practice by telephone and routine appointments.

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.

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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Following our announced comprehensive inspection we took urgent action to suspend Dr Ranam Al Ghazzi’s CQC registration which prevented the provider from delivering regulated activities. A new provider is now carrying on the regulated activities from the location.

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