Archived: Kingsway Surgery

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection at Kingsway Surgery on 11 November 2015.

Overall the practice is rated as inadequate.

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

Specifically, we found the practice to be inadequate for providing safe, effective, responsive and well-led services.

The concerns which led to a rating of inadequate in safe, effective, responsive and well-led apply to all population groups using the practice. Therefore, all population groups have been rated as inadequate.

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

• Systems, processes and practices did not keep people safe. As a result, patients were at risk of harm. Staff did not assess, monitor or manage risks to people who use the service. People received care from inappropriately qualified staff. The practice had employed an overseas trained doctor to work as a health care assistant and practice manager. This person did not have UK accredited training and competencies to work as a health care assistant. The partners were aware of this but had failed to recognise the risk associated with it. Furthermore, recruitment checks had not been carried out on this member of staff.

• 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. The practice did not have adequate systems for medicines and infection control management.

• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.

• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.

• Patients we spoke with were positive about their interactions with staff and said they were treated with compassion and dignity. However, national GP survey data showed the practice was below local / national average for most caring indicators.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

Following the inspection on 11 November 2015; we issued a Warning Notice for Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) on 23 November 2015. The provider was told to suspend all clinics and clinical work undertaken by the healthcare assistant. This was because of the concerns we found regarding the clinical work the health care assistant was undertaking without UK accredited training and lack of supervision. Following this, we visited the practice unannounced on 1 December 2015 to check that the provider had taken action as required. On this visit we found that the provider had taken the required action and had suspended the health care assistant from undertaking all clinical work.

The areas where the provider must make improvements are:

• Introduce effective processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Take action to address identified concerns with infection prevention and control practice.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

• Carry out clinical audits including re-audits to ensure improvements have been achieved.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.

• Actively seek to involve patients in developing and improving the service.

• Ensure systems are implemented for the safe management of prescription pads.

• Ensure accessible availability of medical emergency equipment and a system must be in place to ensure that this equipment is checked on a regular basis

• Ensure they have effective arrangements in place to safeguard children and vulnerable adults .

However there were areas of practice where the provider should make improvements:

• The practice should ensure that information relating to the availability of language translation services is advertised to patients.

I am placing this practice in special measures. Practices 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 practice 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice