Coatham Surgery

We carried out an announced comprehensive follow-up inspection at Drs Summers & Zaman (known as The Coatham Surgery) on 26 June 2019 as part of our inspection programme.

We undertook an inspection of this service as a 12-months comprehensive follow-up to our May 2018 findings. At our May 2018 inspection (report published July 2018) we rated the location as Requires Improvement overall. The link to these July 2018 reports is

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 now rated this practice as inadequate overall.

At our May 2018 inspection we rated the practice as requires improvement because; recruitment checks were not in line with practice policy, the process for recording significant events was ineffective, Patient Group Directions were out of date and there were poor arrangements for recording safeguarding referrals.

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

• The practice did not have clear systems and processes to keep patients safe.
• Receptionists had not been given sufficient 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 timely reviews of medicines.
• The practice did not learn and make improvements when things went wrong.
• The arrangements in respect of infection prevention and control needed improving.

At our May 2018 inspection we rated the practice as good for providing effective and responsive services.

We have now rated the practice as requires improvement for providing effective and responsive services because:

• There was limited monitoring of the outcomes of care and treatment.
• The way the practice organised and delivered services did not always meet patients’ needs. Patients could not always access care and treatment in a timely way.

These areas affected all population groups so we have now rated all population groups as requires improvement.

At our May 2018 inspection we rated the practice as good for providing caring services.

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

• There were poor results in some areas of the national GP patient survey.
• The practice has not engaged sufficiently with patients (for example through a patient participation group).

At our May 2018 inspection we rated the practice as requires improvement for providing well led services. This was because; The provider's incident reporting system was not robust or effective enough, Staff appraisals were overdue, audit and quality improvement activity we viewed was not adequate, and safeguarding activity was not well communicated between practice individuals and was not always discussed with the practice's safeguarding lead.

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

• While the practice had made some improvements to incident recording since our inspection in May 2018, it had not appropriately addressed; analysis, root cause, appropriate action, and learning and dissemination of these events.
• The monitoring and recording of emergency equipment was not adequate.
• 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 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.
• The practice did not always act on appropriate and accurate information.
• Information was not acted on in a timely way.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

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