Catherine House Surgery

Updated 21 October 2022

Catherine House Surgery is located in the town of Totnes, Devon at:

Catherine House Surgery

Totnes

Devon

TQ9 5WB

The provider is registered with CQC to deliver the regulated activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Devon Clinical Commissioning Group (CCG) and delivers personal medical services (PMS) to a patient population of approximately 4,076. This is a contract between general practices and NHS England for delivering services to the local community.

Information published by Public Health England shows that deprivation within the practice population group is in the lower decile (seven of 10) range. The lower the decile, the more deprived the practice population is relative to others.

The age distribution of the practice population closely mirrors the local and national averages.

There is a team of four GPs at the practice comprising of two GP partners and two salaried GPs. The practice team also consists of two nurse practitioners, healthcare assistants and a clinical pharmacist who works across the primary care network (PCN). The clinical team are supported by a management team, reception and administration staff.

Patients using the service also have access to community staff including community matron, district nurses, health visitors and counsellors.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, GP appointments have been available via telephone consultations. If a clinician decides a patient requires a face-to-face appointment or a patient prefers a face-to-face appointment, then anappointment to be seen is made.

The practice is open between 8am and 6.30pm Monday to Friday. Extended hours appointments are offered every Wednesday 6.30pm – 8pm. Outside of these hours, patients are signposted to contact the NHS 111 and Out of Hours services. Information is provided on the practice telephone message and website.

Updated 21 October 2022

We carried out an announced inspection at Catherine House Surgery on 13 April 2022. Overall, the practice is rated as Requires Improvement.

Safe - Inadequate

Effective – Requires Improvement

Well-led – Requires Improvement

Following our previous inspection on 31 March 2016 the practice was rated Good overall and Good for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Catherine House Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection incorporating remote searches, interviews of staff and a site visit.

• The ratings for Caring and Responsive were carried forward from the previous inspection. Both are rated Good.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit
• Conducting an interview with a Patient Participation Group member
• A pre-site visit staff questionnaire
• Obtaining written feedback from patients about the practice
  
  

Our findings

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 rated this practice as Requires Improvement overall.

We have rated Safe as Inadequate, because we found:

• Searches highlighted a number of patients potentially at risk due to a lack of monitoring or diagnosis.
• We found no recorded reason and limited documentation in clinical records where polypharmacy presented significant risks to patients.
• The practice was unable to evidence that all patients diagnosed with long-term conditions had received a review to ensure treatment continued to meet their needs. The practice did not have effective systems to review new patients’ medicines in a timely way after registering with the practice.
• Systems in place to learn and make improvements when things went wrong were not fully embedded.
• The practice did not have effective systems for the appropriate and safe use of medicines, including medicines optimization.
• Infection and prevention control processes were not fully embedded.

However, we found areas where safety was effective:

• There were clear systems, practices and processes to keep people safe and safeguarded from abuse.
• There were adequate systems to assess, monitor and manage risks to patient safety.
• Staff had the information they needed to deliver safe care and treatment.

We rated Effective as Requires Improvement because we found:

• Patient’s needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance.

However, we found areas of effective care and treatment:

• The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles.
• Staff were consistent and proactive in helping patients to live healthier lives.

We rated Well Led as Requires Improvement because we found:

• Overall governance arrangements did not provide sufficient assurance of ongoing resilience and evidence of effective management of risks as an expanding practice.
• Processes for managing risks, issues and performance were not fully embedded. They did not provide assurance that all risks were mitigated as far as reasonably practicable.

However, we found areas of positive leadership, culture and improvement:

• There was compassionate, inclusive and effective leadership at all levels.
• The practice had systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.
• There was a demonstrated commitment to using data and information proactively to drive and support decision making.
• The practice involved the public, staff and external partners to sustain high quality and sustainable care.
• There was evidence of systems and processes for learning, continuous improvement and innovation.

We found breaches of regulations, the provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Implement regular infection prevention and control (IPC) audits to ensure measures including hand hygiene are effective and embedded.

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