Archived: Charterhouse Surgery Also known as The Charterhouse Surgery

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of the practice on 5 April 2016. The practice was rated Requires Improvement overall with Inadequate in safe and requires improvement in effective, responsive and well-led and good in caring.

We undertook this follow-up comprehensive inspection on 24 November 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. Overall the practice is rated as Inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example there was no robust system in place for the monitoring of patients on high risk medicines.
• The practice did not have a business continuity plan in place for major incidents; they had not undertaken a health and safety risk assessment of the premises, fire legionella and asbestos risk assessments to ensure safety of the staff and patients.
• The practice had not undertaken an infection control audit and did not have a safe system in place for monitoring of emergency medicines and vaccines stored in the refrigerators.
• There was no evidence of appraisals for most non-clinical staff.
• There was limited evidence that the practice was comparing its performance to others; either locally or nationally.
• Staff were clear about reporting incidents, near misses and concerns and there was some evidence of learning and communication with staff.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• Information about services were available; however the practice did not have a complaints leaflet and practice leaflet was not up to date.
• During the day of inspection patients reported difficulties in accessing routine and emergency appointments and also reported difficulty in accessing the surgery by phone.
• The practice had a leadership structure; however had limited formal governance arrangements.

There were areas of practice where the provider must make improvements:

• Ensure there is a clear system in place for the implementation and monitoring of medicines and safety alerts and a safe system in place for the monitoring of patients on high risk medicines.
• Ensure face to face basic life support training is provided for all staff.
• Ensure records are maintained when checking the working status of a defibrillator.
• Ensure all patient group directions are authorised and signed by relevant staff.
• Ensure that a fire, legionella, asbestos and health and safety risk assessment of the premises is undertaken and the recommendations following the risk assessments are actioned. Ensure that an infection control audit is regularly undertaken and that any recommendations identified are actioned.
• Ensure the system in place for the monitoring of emergency medicines and vaccines stored in the refrigerators is safe and there is a system for monitoring of refrigerator temperatures.
• Ensure that a business continuity plan is in place to identify how the practice will deal with a range of major incidents such as power failure or buildings damage.
• Ensure that regular appraisals are undertaken for all staff.
• Consider how patients would call for help from the patient toilet.

There were areas of practice where the provider should make improvements:

• Review the quality improvement process so it demonstrates that changes are made following the completion of audits and monitored through re-audits.
• Review the care and treatment provided to ensure that the outcomes for patients with long term conditions are improved.
• Review how patients with caring responsibilities are identified to ensure information, advice and support can be made available to them.
• Review practice information to ensure it is up to date and gives patients information about the services provided and how to make a complaint and that complaints are widely discussed with all staff.
• Review result of the national GP patient survey results and address low scoring areas to improve patient satisfaction especially in access.

We are placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Charterhouse Surgery on 5 April 2016. Overall the practice is rated as requires improvement.

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

• There was no effective system in place for reporting and recording significant events, the practice had no incident reporting policy and staff demonstrated little or no learning from incidents.
• Risks to patients were not always assessed and managed in line with the policy.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was not aware of and complied with the requirements of the Duty of Candour.

There were areas of practice where the provider must make improvements:

• Ensure that a fire, asbestos and legionella risk assessments are undertaken and that recommendations following these risk assessments are actioned. Ensure that the fire exits meet requirements. Ensure that infection control audits are undertaken on a regular basis.
• Ensure that the necessary recruitment checks and procedures are undertaken before employing permanent and locum staff.
• Ensure that there is a system for the reporting and recording of significant events and that all relevant staff are involved in the discussion of significant events and that lessons learned are shared with all relevant staff. Ensure that there is a business continuity plan is in place for major incidents such as power failure or building damage.
• Ensure that the chaperone processes are in line with guidelines and that staff have been trained and undertake a risk assessment to ascertain if DBS checks are required for all staff who undertake this role.
• Ensure that all staff complete mandatory training.
• Ensure yearly appraisals are performed for all practice staff.
• Ensure that there are enough clinical staff to provide appropriate levels of care.

There were areas of practice where the provider should make improvements:

• Consider the safe storage of patient records.
• Review the system in place for the dissemination and monitoring of safety alerts.
• Review the process to identify carers and for the carers register to be up-to date.
• Review the quality improvement process so it demonstrates that requisite changes are made following the completion of audits and monitored through re-audits.
• Review the care of patients with long term conditions so their needs are met.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice