Archived: Boundary House Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boundary House Surgery on 9 December 2015. The overall rating for the practice was requires improvement. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out an announced follow-up inspection at Boundary House Surgery on 21 September 2016. The practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall and urgent enforcement action was taken to suspend the provider of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. The practice was also placed in special measures for a period of six months. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out a further announced comprehensive inspection on 21 March 2017. The practice was rated as good for providing caring services, requires improvement for providing safe and responsive services but continued to be rated inadequate for providing effective and well-led services and was rated inadequate overall. The practice was issued with a requirement notice and remained in special measures as it had not made sufficient improvements to achieve compliance with the regulations.

This inspection was an announced comprehensive inspection on 29 November 2017 and was undertaken following the extended period of special measures to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall the practice is now rated as requires improvement.

The reports from the December 2015, September 2016 and March 2017 inspections can be found by selecting the ‘Reports’ link for Boundary House Surgery on our website at http://www.cqc.org.uk/location/1-583321983.

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Our key findings at the November 2017 inspection were as follows:

• When we inspected in March 2017, we were told that the practice had initiated the process to add two new GP partners to the practice’s registration. At this inspection, we saw that this process had been completed in that a GP who had been a partner at the time of the previous inspection had resigned from the partnership and had been employed as a salaried GP at the practice.
• Clinicians had a thorough knowledge and understanding of the patient management and document management systems.
• The practice had commenced a programme of quality improvement initiatives and had carried out one completed audit cycle as well as undertaking three further single cycle audits.
• There was a failsafe system in place to ensure that urgent referrals were received by secondary care providers and patients received and attended appointments. When patients did not attend appointments, the practice would contact them and encourage them to attend a re-arranged appointment.
• Data showed patient outcomes had improved since the previous inspection in March 2017 and were now similar to the national average for most indicators.
• Improvements which had been put in place with the support of a caretaker practice had been embedded in the practice and were understood and overseen by practice management.
• When we inspected in March 2017, systems to manage clinical correspondence in a safe and timely manner were still relatively new and we were not assured that these would be sustainable when the support of the caretaker practice was withdrawn. At this inspection, we saw that these systems had been successfully maintained.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had undertaken a recent fire drill and had reviewed the exercise to identify and carry out learning actions.
• The practice had engaged with commissioners to change the leadership structure to improve governance and bring about improvements to patient outcomes.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity although some patients said they had concerns about continuity of care by some clinicians.
• The practice had continued to take action to reduce waiting times for appointments.
• The practice business continuity plan had been reviewed to ensure it contained accurate information.

The areas where the provider should make improvement are:

• Continue to assess and monitor the performance of the practice with a view to improving clinical outcomes for patients such as those with diabetes.
• Continue to monitor patient satisfaction and consider taking further actions to bring about improvements so that practice performance is in line with national survey results.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by 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 Boundary House Surgery on 9 December 2015. The overall rating for the practice was requires improvement. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out an announced follow-up inspection at Boundary House Surgery on 21 September 2016. The practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall and urgent enforcement action was taken to suspend the provider of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. The practice was also placed in special measures for a period of six months. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

A caretaker practice was put in place by NHS England to provide primary medical services to patients of the practice during the period of the suspension.

The full comprehensive report on the December 2015 and September 2016 inspections can be found by selecting the ‘all reports’ link for Boundary House Surgery on our website at www.cqc.org.uk.

This inspection was undertaken prior to the end of the six month suspension period whilst the practice remained in special measures on 21 March 2017. Overall the practice is still rated as inadequate.

Our key findings were as follows:

• It was unclear whether concerns about the lead GP’s lack of knowledge of the patient record management system had been addressed as they had been unable to undertake training during their absence from the practice. Following the inspection, the lead GP told us they could use all systems at the practice but we did not see evidence to support this.

• When we inspected in September 2016, we were told that difficulties recruiting permanent GPs had a significant impact on the lead GP’s capacity to manage the practice. Since the inspection, the practice had recruited two new GP partners to the practice and the process of adding these to the practice’s CQC registration was ongoing.

• There was some evidence of recent clinical and non-clinical audit being carried out at the practice. However, there was no evidence that these had been used to bring about improvements.
• Data showed patient outcomes for some conditions were low compared to the national average although current but unvalidated data indicated that these had recently begun to improve.

• The practice had worked closely with a caretaker practice, the local clinical commissioning group and NHS England to improve leadership capacity and governance arrangements. However, as the lead GP had been absent from the practice since the September 2016 inspection, their contribution to improvement was limited. We were told the lead GP had had a role in developing the action plan produced in response to the September 2016 inspection report, but this action plan had been substantially realised and implemented by the caretaker practice and practice management. Following the inspection, the lead GP responded by telling us that they had been significantly involved in bringing about improvements at the practice but we did not see evidence of this during the inspection.

• With the support of the caretaker practice, the practice had put effective systems in place to manage clinical correspondence in a safe and timely manner.

• There was now an open and transparent approach to safety and a system in place for reporting and recording significant events.

• The practice was actively engaging with commissioners to change the leadership structure to improve governance and bring about improvements to patient outcomes.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity although some patients said they had concerns about continuity of care by some clinicians.

• The practice had taken action to reduce waiting times for appointments.

• The practice had a number of policies and procedures to govern activity and had recently reviewed and updated these.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all clinicians have a thorough knowledge and understanding of the patient management and document management systems.
• Ensure that the practice’s quality improvement programme includes effective audit arrangements that drive improvement across key clinical outcomes.

In addition the provider should:

• Continue with plans to change the leadership structure at the practice to improve quality of service provision.

• Continue to closely monitor systems used to review and act on clinical correspondence to ensure all correspondence is acted upon without delay and that decisions made about patient care are clearly documented in the clinical patient’s notes.
• Continue to closely monitor systems used to refer patients to secondary care to ensure that these are fully embedded into practice procedures.
• Continue to ensure management arrangements for overseeing performance (for example QOF) in the practice are robust and that actions are recorded, planned, implemented and reviewed.
• Make arrangements to carry out regular fire drills.
• Review patient access and availability of appointments to better meet the needs of patients.

• Continue to take action to reduce the length of patient waiting times for GP consultation.

• Review the practice business continuity plan to ensure that information is up to date.

This service was placed in special measures in February 2017. Insufficient improvements have been made such that there remains a rating of inadequate for providing effective services and well-led services. The service will remain in special measures, be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we will move to 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.

Professor Steve Field CBE FRCP FFPH FRCG 

Chief Inspector of General Practice