Archived: Priory Avenue Surgery

Updated 22 January 2015

The practice provides personal medical services to over 8,050 patients in Caversham, Berkshire. There was an older than average practice population, with a high proportion of patients aged over 65, and low deprivation scores.

The practice occupies a victorian building in a prominent location on the main road through Caversham. The building was converted for general practice usage and had been extended several times in the last 10 years to meet patient needs. Consultation and treatment rooms are spread over the ground and first floors. The practice does not have onsite parking facility for patients. Limited disabled parking was available for patients with restricted mobility.

Care and treatment is delivered by a number of GPs, practice nurses and health care assistants. Outside normal surgery hours patients were able to access emergency care from an Out of Hours (OOH) provider. Information on how to access medical care outside surgery hours was available on the practice leaflet, website and in the waiting area.

The practice had undergone significant management changes in the last two years and included partnership changes in 2012. The former partnership dissolved and the practice was handed over to NHS Berkshire West Primary Care Trust (PCT) in September 2012. The current management, Specialist Health Service Ltd (SHS) tendered for and took over the practice. They have been running the practice since August 2013 and have an eight year contract with NHS England. The practice is now part of the North and West Reading Clinical Commissioning Group.

The current management team comprises of four directors. Two of the directors are GPs, but do not practise at the Priory Avenue Surgery. The third director is a retired GP and the fourth director is a business/practice manager at Priory Avenue Surgery. GP consultations are solely delivered by salaried and locum GPs and have been since the new practice was formed in August 2013.

A team of salaried doctors were recruited in 2013 and after some initial issues and changes, the medical service provision appeared to be stabilising. However, due to the increasing management and leadership concerns there have been a series of resignations in July and August 2014 from many of the salaried GPs. As a result management at the practice has become a major challenge and the practice experienced significant difficulties in recruiting new salaried GPs.

NHS England has received an action plan from the practice outlining the action they are planning to take to resolve the staffing and management issues identified in the previous eight weeks. This was agreed in November 2014 and the actions required are currently in progress. The action plan will be reviewed by NHS England. The clinical commissioning group are also involved in the recovery plan and supporting the practice.

The practice has a Alternative Personal Medical Services (APMS) contract. APMS agreements are locally agreed contracts between NHS England and a GP practice. This was a comprehensive inspection.

The practice provides services from

Priory Avenue Surgery, 2 Priory Avenue, Caversham, Reading, Berkshire, RG4 7SF.

Updated 22 January 2015

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of Priory Avenue Surgery on 27 November 2014. The practice was rated inadequate in the safe, effective and well led domains. The practice was rated requires improvement in the caring and responsive domains.

Our overall rating for the practice was inadequate.

On the basis of the ratings given to this practice at this inspection I am placing the provider into special measures.

Our key findings were as follows:

Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. We saw staff treated patients with kindness and respect, and maintained confidentiality.

Some patients reported considerable difficulty in accessing a named GP and they experienced a poor continuity of care. However, all patients told us urgent appointments were usually available the same day.

Patients were at risk of harm because systems and processes were not in place in a way to keep them safe. The practice was going through a significant staffing crisis and there had been severe staff disruption in recent months. The practice was working closely with the NHS England area team to ensure they took immediate corrective action, which would enable them to fulfil their basic functions safely. The North and West Reading Clinical Commissioning Group were also monitoring the concerns and issues within the practice.

We saw no evidence that audit was driving improvement in performance to improve patient outcomes. We found, the recent staff shortages had an adverse impact on patient records. This posed a significant risk to patient safety as their patient records were not up to date with recent test results and discharge information from hospital. Therefore, patients may not have received appropriate follow up treatment or care.

There was no formalised induction programme for new administration and reception staff. However, training had taken place and staff felt supported by their immediate team and manager.

The practice did not have a clear vision and strategy. Staff we spoke with were not clear about their responsibilities in relation to the vision or strategy. There was no clear leadership structure and staff did not feel supported by the directors.

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

Importantly, the provider must :

• Document all recruitment and employment information required by the regulations in all staff members’ personnel files.
• Ensure all staff identified as requiring a criminal records check through the Disclosure and Barring Service (DBS) have one undertaken as soon as possible.
• Carry out risk assessments and document these to inform which members of staff required a DBS check and which staff did not.
• Take immediate corrective action to address current staffing issues to ensure safe minimum levels are reached.
• Implement a system to ensure all staff members receive regular supervision and appraisal.
• Provide clinical leadership and management to all practice staff.
• Develop a clinical audit process and implement findings from audits.
• Develop and maintain a system to identify risks and improve quality in relation to patient safety.
• Implement a process to disseminate learning from significant events, clinical audits, complaints and referral, to practice staff members.
• Take immediate action to ensure all patients’ records are updated with appropriate information and documents in relation to the care and treatment they have received.
• Undertake and record all relevant risk assessments.
• Undertake regular infection control audits that are documented and introduce a cleaning schedule for practice equipment.

Action the provider SHOULD take to improve:

In addition the provider should:

• Introduce a legionella risk assessment and related management schedule.
• Organise an induction programme for all new starters.

On the basis of this inspection and the ratings given to this practice the provider has been placed into special measures. This will be for a period of six months when we will inspect the provider again.

Special measures is designed to ensure a timely and coordinated response to practices found to be providing inadequate care.

We are currently piloting our approach to special measures, working closely with NHS England. The proposals we are piloting are that GP practices rated as inadequate for one or more of the five key questions or six population groups will be inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, they have failed to make sufficient improvement, and are still rated as inadequate for a key question or population group, we will place them into special measures. In a small number of cases, a GP practice will have such significant problems that people who use services are at risk or there may be sufficiently little confidence in the practice’s capacity to improve on its own. In these instances the practice will be placed straight into special measures.

Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid having its registration cancelled.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Updated 22 January 2015

Flu immunisations were offered to ‘at risk’ patients. This group of patients, were invited for regular reviews. Patients with long term conditions had a care plan in place to prevent unplanned admissions. Diabetic eye screening appointments were offered at the practice. The practice held dedicated clinics for patients diagnosed with conditions such as diabetes, respiratory and cardiovascular disease. The practice had robust recall systems in place to ensure patients with long term conditions received appropriate monitoring and support. Patients had an annual review of their condition and their medication needs were checked at this time. However, patient records and test results were not always being processed and reviewed in a timely way. Therefore this increased the risk of patients receiving delayed treatment and care.

Updated 22 January 2015

Childhood immunisations were carried out at the practice. Antenatal, baby checks and family planning clinics with a GP were available. Cervical screening was offered at the practice. We saw that the waiting area and treatment rooms were able to accommodate patients with prams and buggies. Accessible toilet facilities were available for all patients attending the practice including baby changing facilities. Chlamydia testing was offered to 15 to 24 year old patients. The salaried GPs of the practice told us that they were unable to attend to their full range of duties due to the staff shortages. This included the review of safeguarding action plans and risks to individual patients.

Updated 22 January 2015

Patients over 75 years of age had a named GP. However, due to staff shortages this was not being maintained. Patients reported that they were unable to see the same GP and this had impacted upon the continuity of their care. Home visits were arranged for housebound patients. The practice provided medical services to two local nursing homes. The practice ran various clinics to support elderly patients. These included specialist wound care, minor operations and Doppler clinics. Flu immunisations were offered to patients over 75 years. The practice data showed 79% of older patients had been vaccinated. The practice also ran vaccination clinics for shingles and pneumonia for older people. The practice provided community enhanced services to all over 75 years of age patients.

Updated 22 January 2015

The practice provided a range of appointments between 8am to 8pm. The practice was also open two Saturdays each month. At the time of the inspection the extended hours appointments had been reduced due to the staff shortages. This reduced the availability of access to patients who worked and we unable to visit the practice during working hours. Telephone calls to patients who were at work were made at times convenient to them. There was an online appointment booking system and repeat prescription service. The practice also offered NHS Health Checks to all its patients aged 40-75, in line with national guidelines.

Updated 22 January 2015

Longer appointments were available for people who needed them, such as those suffering from poor mental health. A drug counsellor held a monthly session at the practice and appointments were offered to patients for this. The practice referred patients to appropriate mental health services. The referrals to other NHS services had not always been monitored or reviewed by the practice within their clinical governance processes. Practice data identified that the overall referral rates had increased recently. We were unable to evidence how the practice ensured their appropriateness and whether they were in line within current local and national referral guidance.

Updated 22 January 2015

The practice held a register of patients with learning disabilities. We saw 36 patients were recorded on the register, of which eight patients had received a health review. A GP carried out ward rounds for all patients with learning disability in a local care home. All vulnerable patients were prioritised, and given same day appointments. The practice provided medical services to homeless patients and temporary residents. Interpreters were used for patients whose first language was not English. Patients in vulnerable circumstances were at risk of delayed care and treatment, due to the shortage of GPs in the practice. The practice systems to review the care and support of those in vulnerable circumstances were not effective. The lack of leadership in the practice meant there was limited oversight and review of the patient population. This included changes to tailor the practice services to the needs of their population.