The Care Quality Commission
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Archived: Quincy Rise Surgery

Overall: Good read more about inspection ratings

30 Sandringham Way, Brierley Hill, West Midlands, DY5 3JR (01384) 422698

Provided and run by:
Quincy Rise Surgery

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

All Inspections

23 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We first inspected Quincy Rise Surgery across two dates on 9 March and 4 April 2016.

As a result of our inspection visits, the practice was placed in special measures and was rated as Inadequate overall. This was because we identified regulatory breaches in relation to regulation 12 for providing safe care and treatment and regulation 17 due to inadequate governance arrangements. As breaches of legal requirements were found we issued the following warning notices:

  • A warning notice informing the practice that they were required to become compliant with specific areas of Regulation 12: safe care and treatment HSCA (RA) Regulations 2014, by 17 July 2016.
  • An additional warning notice informing the practice that they were required to become compliant with Regulation 17: Good governance HSCA (RA) Regulations 2014, by 6 September 2016.

Furthermore, we identified areas where the provider must make improvements and additional areas where the provider should improve. In addition to the warning notices, a requirement notice was also issued for specific aspects of Regulation 12: safe care and treatment HSCA (RA) Regulations 2014.

We carried out an announced focused inspection at Quincy Rise Surgery on 18 July 2016 to focus on the areas identified in the warning notice for Regulation 12 of the HSCA (RA) Regulations 2014. Although we saw that some improvements had been made, the practice did not fully meet the requirements of the warning notice for Regulation 12: safe care and treatment HSCA (RA) Regulations 2014.

We carried out an announced comprehensive inspection at Quincy Rise Surgery on 23 November 2016. This inspection was conducted to see if improvements had been made in line with the special measures period of six months following publication of the final report. Additionally, we conducted this inspection to focus on the areas identified in the warning notice for 17: Good governance HSCA (RA) Regulations 2014. This inspection was conducted to see if improvements had been made in line with the required completion date of 6 September 2016.

You can read the reports from our previous inspections, by selecting the 'all reports' link for Quincy Rise Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

  • During our inspection we saw that staff were friendly and helpful and treated patients with kindness and respect. We noted a theme of positive feedback from patients we spoke with during our inspection and across completed CQC comment cards.
  • During our previous comprehensive and focussed inspections we found that the practice did not have an effective system in place to ensure that the relevant monitoring was in place prior to prescribing high risk medicines. As part of our most recent comprehensive inspection we saw evidence to support that patients on high risk medications were appropriately monitored and up to date with relevant blood tests.
  • During our previous comprehensive and focussed inspections we identified gaps in record keeping which indicated that patients had not received medication reviews in line with their needs. We found that record keeping had significantly improved during our most recent inspection. Practice data demonstrated that patients received regular medication reviews and patients had care plans in place.
  • We noted that the practice had worked on many improvements since our previous comprehensive inspection. For instance, risks associated with health and safety, fire and infection control had been formally assessed. The management of staff files had improved significantly and the practice gathered feedback from patients and staff through surveys and by implemented formal action plans. The practice also had effective systems, processes and practices in place to keep people safeguarded from abuse.
  • The practice had worked on developing a programme of audits since our previous comprehensive inspection. Some of these audits had been repeated and demonstrated improvements.
  • However, we noted in other areas that governance, systems and processes were not always effectively operated to support a well led and open cultured team. We noted that in areas the team was disjointed and although there was a regular programme of meetings in place not all staff were invited to the meetings. Additionally, at the point of our inspection we found that not all staff had received an appraisal. Furthermore the practice did not maximise opportunities to share learning, monitor themes and reflect on events across the whole team.

The areas where the provider should make improvements are:

  • Ensure that governance arrangements are established and effectively operated to support a well led and open cultured team.
  • Ensure that effective leadership is sustained in the practice in order to enable and support the team to continue to embed improvements.
  • Continue to support staff and ensure that a regular programme of appraisals is in place as part of this process.
  • Review themes from significant events and complaints and maximise opportunities to share learning and good practice across the whole practice; using these as opportunities to proactively drive improvement.
  • Ensure that policies are well embedded to support processes such as chaperoning and review complaints policies to ensure feedback from all avenues are considered, such as online feedback from NHS Choices and verbal complaints.
  • Continue to identify carers in order to provide further support where needed.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Quincy Rise Surgery across two dates on 9 March and 4 April 2016. Breaches of legal requirements were found and after the comprehensive inspection we issued the following warning notices:

  • A warning notice informing the practice that they were required to become compliant with specific areas of Regulation 12: safe care and treatment HSCA (RA) Regulations 2014, by 17 July 2016.
  • An additional warning notice informing the practice that they were required to become compliant with Regulation 17: Good governance HSCA (RA) Regulations 2014, by 6 September 2016.

The practice wrote to us in response to the warning notices to say what they would do to meet legal requirements in relation to Regulations 12 and 17

We carried out an announced focused inspection at Quincy Rise Surgery on 18 July 2016 to focus on the areas identified in the warning notice for Regulation 12of the HSCA (RA) Regulations 2014. This inspection was conducted to see if improvements had been made in line with the required completion date of 17 July 2016. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Quincy Rise Surgery on our website at www.cqc.org.uk.

Our key findings across all the areas we inspected were as follows:

  • The arrangements for managing emergency medicines and vaccinations in the practice ensured that patients were kept safe. There were also contingency plans in place to support the practice in the event of a major incident and a break in the cold chain, and for the safe handling of vaccinations.
  • The practice had made improvements in a number of areas by developing practice specific policies and ensuring key processes were embedded in the practice. Safety alerts were disseminated by the practice manager and records were kept to demonstrate action taken. There were effective arrangements in place for the management of risk which supported the safety of the premises, and we also saw areas where risks had been effectively mitigated.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

However we found that although some improvements had been made, improvements were not sufficient enough to ensure that patients were receiving medication reviews in line with care and treatment requirements. Overall, ineffective use of the practice’s patient record system resulted in an inaccurate reflection of patient medication reviews. For example:

  • We identified cases where poor record keeping and ineffective use of the patient record system had resulted in a lack of detail across some care plans, and medication reviews that had not been effectively coded.
  • Additionally, we found that regular reviews had not always taken place in line with patients’ medication changes and needs.

Therefore the practice has not fully met the requirements of the warning notice for Regulation 12: safe care and treatment HSCA (RA) Regulations 2014.

This service was placed in special measures in April 2016 and is due to be inspected again within six months of that date. When we re-inspect, we will also look at whether further progress has been made to complying with Regulation 12: safe care and treatment HSCA (RA) Regulations 2014; including specific areas for improvement such as record keeping, medicines management and clinical coding. During our re-inspection we will also see if improvements had been made in line with the warning notice which was issued for Regulation 17: Good governance HSCA (RA) Regulations 2014.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 March 2016 and 4 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Quincy Rise Surgery on 9 March 2016 and an announced focussed inspection on 4 April 2016. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

  • Governance arrangements were not robust. Significant event records lacked key information. Minutes of meetings did not reflect a culture of learning and patient outcomes were hard to identify, as little or no reference was made to audits or quality improvement.
  • We identified a number of gaps in the arrangements for identifying, recording and managing risks and we found many gaps in the record keeping for staff files. Appraisals were overdue for some members of staff and the practice did not have an induction pack for locum’s clinicians to use when working at the practice.
  • The arrangements for managing medicines, including vaccinations, were not robust to ensure that patients were kept safe.
  • During our inspection we found that care plans were not in place across practice registers and that some records did not represent that adequate medication reviews had taken place. These included patients on the practices dementia, mental health, learning disability and palliative care registers.
  • Staff demonstrated they understood their responsibilities and how to respond to a safeguarding concern; however we received mixed feedback with regards to identifying who the safeguarding lead was at the practice.
  • Notices in the patient waiting room told patients how to access a number of support groups and organisations, however there was no information available to specifically support carers.
  • We observed a friendly atmosphere throughout the practice during our inspection. Although staff spoke positively about working at the practice, not all staff said that they felt supported.
  • The practice did not have an action plan in place to demonstrate how improvements to the service could be made. For example, the practice had not reviewed their results from the national GP patient survey and no action plans were in place to improve appointment waiting times.
  • We noticed that members of staff were courteous and helpful to patients both attending at the reception desk and on the telephone.

The areas where the provider must make improvements are:

  • Ensure that safety alerts (such as medicines and medical device alerts) are effectively managed in the practice to ensure that action is taken where necessary in relation to patient safety alerts which impact on service users.
  • Improve the overall management of Human Resources; ensure that the appropriate disclosure and barring (DBS) and recruitment checks have been completed for all staff as required, prior to working at the practice.
  • Ensure that risk is assessed in the absence of DBS checks for members of the team who provide a chaperone service.
  • Ensure that care plans are continually completed in line with patients needs and ensure that medication reviews are always part of patient’s care and treatment assessments as required.
  • Improve the arrangements for managing medicines including vaccinations; ensure that record keeping for the management of cold chain and Patient Group Directives (PDGs) reflect national guidance.
  • Ensure that risk is assessed and managed in relation to premises, equipment and infection control to assure service users and staff that they are safe.
  • Ensure that clinical audits including re-audits are completed to ensure improvements have been identified and achieved.
  • Implement a plan of business continuity to support the practice in the event of a major incident.
  • Engage with and respond to the views of service users and staff and put actions in to place to make improvements where possible.

The areas where the provider should make improvement are:

  • Embed a culture of learning throughout the practice, ensure that key topics such as significant events, incidents and complaints are discussed with staff and recorded as best practice in order to share and monitor learning and action points and to continually apply improvements.
  • Ensure that staff are aware of their own roles as well as the responsibilities of colleagues, including key roles such as the practice leads for safeguarding and infection control.
  • Ensure staff are supported through a programme of regular appraisals.
  • Improve governance arrangements in relation to infection control; ensure that actions are taken to address improvements identified through completed infection control audits. Keep records to support that medical equipment is appropriately cleaned and that the required cleaning has taken place for each area of the practice, including specific areas such as the cleaning of non-disposable curtains used in treatment rooms.
  • Ensure that prescription pads used for home visits are adequately tracked and monitored in line with national guidance.

I am placing this service in 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 population group, 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.

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 six 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.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice