• Doctor
  • GP practice

Bury Road Surgery

Overall: Requires improvement read more about inspection ratings

Gosport War Memorial Hospital, Bury Road, Gosport, Hampshire, PO12 3PW (023) 9258 0363

Provided and run by:
Dr Carl Wyndham Robin William Anandan

Important: The provider of this service changed. See old profile

All Inspections

28 September 2022 and 4 October 2022

During an inspection looking at part of the service

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.

Our findings

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

18 November 2021

During an inspection looking at part of the service

We carried out an announced inspection at Bury Road Surgery on 18 November 2021. Overall, the practice is rated as Inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

Following our previous inspection on 8 January 2020, the practice was rated Requires Improvement overall and for safe and well led key questions but was rated good for providing effective, caring and responsive services.

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

This inspection was a focused inspection to check if previous breaches of regulations had been complied with. We inspected only the following key questions:

  • Safe
  • Effective
  • Well Led

We carried forward, from our previous inspection, the ratings in relation to the following key questions:

  • Caring
  • Responsive

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

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 Inadequate overall

We found that:

  • There continued to be a lack of management and monitoring of practice policies and procedures.
  • There was no policy for the management of infection control in relation to COVID-19.
  • There were gaps in safeguarding procedures.
  • The prescribing practice of non-medical prescribers was not appropriately monitored or audited to ensure safe prescribing.
  • There was no system for the recording, investigation of, and learning from significant events.
  • There was a risk that patients with long term conditions such as diabetes, asthma and chronic kidney disease may not have been appropriately diagnosed and their condition monitored effectively in line with best practice guidelines.
  • There was evidence that patients’ medical conditions were not always fully reviewed and updated.
  • Medicines were not stored safely.
  • There was a lack of central oversight of governance processes.
  • There were gaps in governance processes which had led to the breaches of regulations identified during this inspection.
  • There was a lack of overall assurance and management in relation to risk.
  • The practice was not focused on quality improvement.
  • There was a lack of engagement with staff and patients.

However we also found:

  • Staff were proud to work for a small practice and felt supported in their role.
  • A new practice manager had been recently recruited who had insight into the governance failings in the practice and had developed a project brief to improve the service.

We found breaches of regulations. The provider must:

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

The provider should:

  • 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 Cardio Pulmonary 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.

I am placing this practice into special measures. Services placed in special measures will be inspected again within six 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 six months if they do not improve.

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

8 January 2020

During a routine inspection

We previously carried out an announced comprehensive inspection at Bury Road Surgery on 23 November 2018 as part of our inspection programme. The practice was rated as requires improvement for safe, effective and well-led, and for the six population groups; older people, people with long term conditions; families, children and young people; working age people whose circumstances may make them vulnerable and people experiencing poor mental health. This meant the practice was rated requires improvement overall. We issued requirement notices for Regulation 12: Safe care and treatment and for Regulation 17: Good governance.

This inspection on 8 January 2020 was an announced comprehensive inspection to follow up on the breaches of regulation and as part of our inspection schedule where services rated as requires improvement are subject to re-inspection within 12 months.

This inspection looked at the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

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 rated the practice as good for effective, caring and responsive and good for all population groups apart from the group of patients with long-term conditions, which re have rated requires improvement. We have continued to rate the practice as requires improvement for providing both safe and well-led services.

We rated the practice as requires improvement for providing safe services because:

  • The recruitment process did not define the safety checks required before employing new staff, including role-specific safety checks.
  • There was not a system for checking all staff were up do date with their routine immunisations.
  • There were gaps in the process for checking safe prescribing of high risk medicines and the process had not been formally defined.

We rated the practice as requires improvement for providing well-led services because:

  • Governance systems had not identified where there were gaps in assurance or areas for improvement. There was a lack of oversight of staff training and policy management.
  • Key risks to the organisation had not been identified, managed and reviewed to understand and to promote quality and safety. For example, in response to changes planned for the service, issues with the estate and potential capacity issues from changes in local service provision.

We rated the practice as good for providing effective, caring and responsive services because:

  • Patient needs were assessed and their care and treatment was based on evidence-based guidance.
  • The practice addressed areas where outcomes for patients were below the national average, and worked cooperatively with other organisations involved in patient care.
  • Staff were supported to gain additional skills and qualifications.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • 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:

  • The provider should implement strategies to increase the uptake in cervical screening.
  • The provider should continue to take forward actions identified at the recent fire risk assessment.
  • The provider should consider improvements in recording discussions and decisions in meeting minutes.
  • There should be guidance on how to make a complaint more readily available for patients.
  • The practice should make information about support groups readily available to patients and visitors.
  • The practice should have information available in different formats and languages.

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

23 November 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating March 2018 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? –Good

Are services well-led? - Requires improvement

We carried out an announced focused inspection carried out on 15 November 2018 to confirm that the practice had carried out actions to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 13 March 2018.

At the inspection on 15 November 2018 we found there were continuing shortfalls in the safe domain and service requirement notices in relation to: appropriate support, training, professional development, supervision and appraisal of staff employed by the practice.

We therefore carried out a full comprehensive short notice announced inspection on 23 November 2018, due to the concerns identified on 15 November 2018.

At this inspection we found:

  • The practice managed risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, this was not supported by suitable systems and processes to demonstrate that learning and improvements were embedded in practice and shared appropriately with relevant staff.
  • There were shortfalls in the monitoring of prescription stationery.
  • There were shortfalls in the management of risk from Legionella.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The systems and processes in place for staff appraisals did not show that the practice policy had been consistently followed; and all staff had received appropriate supervision and appraisal.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Systems and processes to support the management and running of the practice were unclear and records were not consistently complete to enable the practice to show it was meeting the regulations at all times.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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:

  • Review arrangements for consultations with patients under the age of 16 years.
  • Review arrangements for the safe monitoring and storage of emergency medicines.
  • Review arrangements for identifying themes and trends from complaints and acting upon these.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Bury Road Surgery on 13 March 2018. The overall rating for the practice was good. The practice was rated as good for providing effective, caring, responsive and well-led services. The practice was rated as requires improvement for providing safe services. The full comprehensive report for March 2018 can be found by selecting the ‘all reports’ link for on our website Bury Road Surgery at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 15 November 2018 to confirm that the practice had carried out actions to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 13 March 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good. However, the practice remains rated as requires improvement for providing safe services. This is because of shortfalls with necessary training, including safeguarding adults and children training, monitoring of emergency medicines and use of Patient Group Directives (PGDs) to administer medicines.

Our key findings were as follows:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • The Practice had implemented an online software training programme and had asked staff to complete necessary training. However, the practice had not implemented a plan of when training would be completed. The majority of staff had not completed necessary training.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Review how the practice is assured that all premises checks, including fire safety and security arrangements, are in place.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

13 March 2018

During a routine inspection

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection of Bury Road Surgery on 13 March 2018, as part of our CQC inspection programme.

At this inspection we found:

  • The practice was supported by a proactive patient reference group who met three to four times a year and there was also a virtual representation of nearly 400 patients.
  • Patient feedback on the day was mainly positive regarding all aspects of care provided by the practice.
  • Appointment times had been extended from 10 to 15 minutes to allow for more time for GPs to address the needs of their patients appropriately.
  • The practice had a designated lead for prescriptions and there were effective procedures to ensure all prescription requests, including medicine changes following hospital discharges, requests for repeat prescriptions or acute medicines requests were handled efficiently and in a timely manner.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was not a clear training schedule or records of mandatory training and updates needed for all staff.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Review how the practice is assured that all premises checks, electrical calibration testing dates and maintenance of equipment at the practice are in place
  • Continue to promote an increased uptake of cervical screening to be in line with the national average.
  • Review how all medicines stored at the practice are monitored including for the management of medicines expiry dates.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice