The Whitestone Surgery in Whitestone, Nuneaton, has been rated inadequate and been suspended from treating people in order to protect them by the Care Quality Commission (CQC) following an inspection in January.
CQC carried out a focused inspection to follow up on information of concern that had been received about the practice.
The overall rating for Whitestone Surgery has dropped from good to inadequate as have the ratings for safe, effective, responsive, and well-led. Caring has dropped from good to requires improvement.
Following this inspection CQC took urgent action to suspend the provider as it believed people were at the risk of significant harm if it didn’t do so. The local integrated care board put in caretaker arrangements to ensure there was no loss of service to people who needed treatment.
Amanda Lyndon, CQC deputy director of operations in the midlands, said:
“When we inspected Whitestone Surgery, we found a practice where the provider couldn’t demonstrate they had the capacity or skills to deliver safe, high-quality care for people who used the practice.
“The service was managing care records and the identification and treatment of people’s conditions poorly. Our record search found two people with chronic kidney disease at stage five (end stage) had been incorrectly recorded in their records as stage four with one not being reviewed since 2012. This meant they may not have received the correct treatment which could potentially be fatal.
“We sampled five records and found four people had a missed diagnosis of diabetes based on their blood results and weren’t receiving the correct management and follow up care for their condition. Likewise, we saw a similar situation for people who weren’t always given the correct dosage of steroid for their asthma. This is unacceptable because it places people at risk of their diabetes or asthma deteriorating and leading to irreversible complications.
“It was incredibly worrying to find that there were over 200 pathology reports dating back to December 2020 that had not been reviewed or actioned. Of these reports 51 showed abnormal results. There were also more than 900 documents awaiting processing, including out of hours reports and clinical documents which needed reviewing and filing into people’s records, or consulted on the findings. It is completely unacceptable that leaders have let important paperwork issues get so out of hand.
“This practice was delivering care and treatment, unsafely, and way below the standards people should be able to accept, which left us with no option but to use our enforcement powers and suspend them from operating.
“While the suspension is in place, CQC has assurance that people are receiving the care and treatment they deserve from a caretaker provider appointed by the NHS Coventry and Warwick Integrated Care Board.
“We will continue to monitor Whitestone Surgery and won’t lift our suspension until we’re assured, they can demonstrate people using the service will receive safe and effective care and treatment. If we return and find there are not enough improvements made, we will not hesitate to take further action even if that means cancelling their registration.”
Inspectors found at Whitestone Surgery:
- There was a no clear leadership or structure at the practice and nothing in place to support good management of the practice
- Inspectors found some staff were working beyond their capabilities
- The child safeguarding register consisted of 11 people, five of the people on the register were adults, one of whom being 32
- The practice didn’t hold any emergency medicines. People were placed at risk of their condition worsening or even death by not receiving appropriate medicines in the event of a medical emergency
- The practice had insufficient equipment to keep patients safe for example, the practices nebuliser machines were not in use, had not recently been safety tested and no medicines were stocked for use with them. Nebulisers are used to deliver medicines to help people struggling to breathe in an emergency. This could place people in a medical emergency at risk of their condition worsening or death in the absence of this equipment
- Nurses and healthcare assistants were administering medicines and vaccinations without patient group directions and patient specific directions in place. These are the legal documents authorising the administration of medicines or vaccinations by healthcare assistants. For example, a healthcare assistant had administered vitamin B12 injections to a person without this authority in place.