We carried out an announced focused inspection at Bury Road Surgery on 28 September 2022. Overall, the practice is rated as requires improvement.
This was a focused inspection and we have carried forward the ratings for caring and responsive from previous inspections.
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - good
Well-led - requires improvement
Following our previous inspection on 18 November 2021, the practice was rated inadequate overall and inadequate for providing safe services and well led. It was rated requires improvement for providing effective care and treatment. We imposed conditions on the provider’s registration (Dr Carl Wyndham Robin William Anandan).
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 concerns and breaches of regulation from the previous inspection.
The focus of this inspection was on:
- The key questions of safe, effective and well-led
- Following up on enforcement actions relating to Regulation 12 and Regulation 17 of the Health and Social Care Act Regulations 2014 (the Act).
- The breach of Regulation 12 (safe care and treatment) was because care and treatment were not provided in a safe way for patients:
- The advanced nurse practitioner was prescribing outside of her competency.
- There was no formal regular clinical supervision offered to nurse prescribers or auditing of their prescribing practice.
- Documented consultations for patients presenting with an exacerbation of asthma did not meet national guidance.
- Patients with long term conditions were not appropriately diagnosed and their condition effectively managed and monitored.
- The breach of Regulation 17 (good governance) was because there was a lack of systems and processes to ensure compliance with the fundamental standards as set out in the Act:
- Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not operated effectively.
- There was no system to manage and monitor policies and procedures.
- A lack of central oversight of governance processes
- We also followed up on issues where we said the provider should make improvements.
- Restart engagement with the patient participation group (PPG)
- Ensure administrative members of staff do not undertake chaperone duties until a disclosure and barring service (DBS) check is in place.
- Put a system in place to show it is clearly flagged in a patient’s record whether there are any safeguarding concerns.
- Review clinical staff records to make sure they reflect immunisations received.
- Improve hand washing standards in the practice.
- Implement a system to catch up a backlog of records summarising.
- Improve the quality of medication reviews.
- Implement a system for the recording investigating and learning from significant events.
- Improve the system for the monitoring and actioning of safety alerts.
- Construct and implement a plan to improve the uptake of cervical screening.
- Strengthen the system for implementing quality improvement as a result of clinical audit.
- Review patients with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) in place to ensure records are complete and appropriately completed.
- Draw up a business development plan to include succession planning.
- Identify a speak up guardian.
- Improve on the use of data to monitor performance
How we carried out the inspection
This inspection was carried out as follows:
- Conducting staff interviews some onsite and some using video conferencing.
- 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.
- A site visit.
We based our judgement of the quality of care at this service on a combination of:
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
- information from the inspection.
We found that:
- There had been improvements in many of the systems to provide safe care. These included: safeguarding training and policies, recruitment checks, infection prevention and control systems, summarising patient records, assessing competency of non-medical prescribers, prescribing policy, setting up systems for recording incidents and safety alerts.
- The practice had adopted clinical templates to support effective care, had a system to invite patients for their health and medicine reviews. It had recruited and trained nurses to increase the capacity for clinics, there were regular staff appraisals and there had been training to complete Do Not Attempt Cardiopulmonary Resuscitation.
- An improvement plan had been implemented and managed since our last inspection and the Patient participation Group had been re-established. A risk register was in place but the approach to risk management was not embedded.
We found three breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients. This includes
- Ensuring handwashing procedures are followed in line with guidance.
- Maintaining safe staffing levels, including GPs.
- Establishing a safe system for responding to tasks.
- Implementing a system to ensure patients with abnormal test results are recalled for monitoring and re-testing (safety netting).
- Ensuring patients with long term conditions have their health needs reviewed in line with clinical guidance.
- Implementing a protocol for reviewing patients with acute exacerbations of asthma.
- Ensuring medicine reviews for people with long term conditions and those who are prescribed medicines or medicine combinations with known risks, are undertaken and documented in line with best practice guidance.
- Ensuring all incidents are fully investigated and learning is identified, shared and monitored.
- Ensuring clinical templates are used effectively in order to improve consistency of care and treatment.
- Ensuring records are completed to show discussions with patients, decisions and any changes made, in line with clinical guidances.
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This includes:
- Developing a detailed succession strategy for the practice.
- Ensuring clinical governance is in place, to identify and manage risks, learn from incidents, complaints and audits and promote improvement in clinical care.
- Continue to comply with the conditions imposed on the provider on 25 January 2022.
The provider should:
- Take steps to engage consistently with the local safeguarding meetings.
- Continue to monitor and deliver the plan to summarise patient records.
- Continue to monitor and encourage take-up of cervical screening.
- Re-establish a clinical audit programme, that reflects local and practice priorities.
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