We carried out a short notice announced focused inspection at Bury Road Surgery on 23 February 2023. Overall, the practice is rated as Inadequate.
This was a focused inspection and we have carried forward the ratings for caring from previous inspections.
Safe - inadequate
Effective - inadequate
Caring - good
Responsive – requires improvement
Well-led - inadequate
Following our previous inspection on 22 September 2022 and 4 October 2022, the practice was rated requires improvement overall. (Requires improvement for key questions Safe, Effective, and Well Led).
We had previously imposed three conditions on the provider’s registration (Dr Carl Wyndham Robin William Anandan) following the inspection on 18 November 2021 to support improvement. This required the provider to send us monthly reports to show progress was being made in identifying, reviewing and managing patients with specific long term conditions effectively.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bury Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up on concerns raised with CQC about the practice’s staffing levels and the safe provision of patient care. We also reviewed progress against the breaches of regulation from the previous inspection.
The focus of this inspection was on:
- The key questions of safe, effective, responsive and well-led.
- To assess the impact of staffing challenges on the delivery of safe services.
- To preview progress against enforcement actions imposed at the last inspection, relating to Regulations 12 (Safe care and treatment), Regulation 16 (Receiving and acting on complaints) and Regulation 17 (Good Governance) of the Health and Social Care Act Regulations 2014.
How we carried out the inspection
This inspection was carried out as follows:
- A site visit.
- Conducting staff interviews, some on-site and some using video conferencing after the visit.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
We based our judgement of the quality of care at this service on a combination of:
- information from our on-going monitoring of data about services and
- information from the provider, patients, the public and other organisations.
- information from the inspection.
We found that:
- The clinical governance systems were not effective to support improvement in the service. We found areas where previous improvements were made had not been maintained. For example, we found systems to ensure oversight of safeguarding, learning from incidents and complaints as well as recruitment processes had not been embedded.
- Although the practice had started to implement an improvement plan, which included actions to arrange and deliver regular reviews of patients with long term conditions and review patients on high-risk medicines, we found this had not been effective. Our remote clinical searches identified high numbers of patients who had not had the care they needed, or their notes did not document details relating to their care.
- Incidents were not fully investigated, and learning was not shared and monitored to deliver improvements in care and treatment.
- Patient records were not completed to reflect discussions with patients, decisions and any changes made, in line with clinical guidance. There continued to be a high number of records requiring summarising, as the staff recruited for this were no longer in place.
- Although previously we found there had been training to complete Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms, at this inspection we found examples of omissions in these forms.
- Complaints were not routinely used to improve the quality of care.
- There were gaps in rotas for staff, including GPs, administration and reception staff.
- Audits were not used consistently to identify where quality and/or safety was at risk in clinical care.
- The risk register was not used effectively as a system to identify, assess and managed risks.
- The practice continued to have a reactive approach to risk management, rather than proactive.
We found four breaches of regulations, 1 new and 3 ongoing. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure there are sufficient numbers of suitably qualified, competent and skilled staff to deliver care and treatment. Ensure all nurses had demonstrated they had completed their required training, for example in safeguarding vulnerable adults and children.
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation. This includes managing the timeframes for responding and ensuring timely clinical involvement.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Continue to comply with the conditions imposed on the provider on 25 January 2022.
The provider should:
- Continue to monitor and encourage take-up of cervical screening.
- Continue to improve the recruitment documentation.
- Formalise arrangements with the landlord so the provider has the assurance that facilities are regularly checked and safe.
- Review leadership and management of safeguarding matters.
I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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 to varying the terms of their registration within 6 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 6 months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services