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Archived: Falmouth Road Group Practice

Overall: Inadequate read more about inspection ratings

78 Falmouth Road, Borough, London, SE1 4JW (020) 7407 4101

Provided and run by:
Falmouth Road Group Practice

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

All Inspections

20 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Falmouth Road Group Practice on 20 October 2016 following previous inspections of the practice on 29 April 2015 and 5 January 2016. As a result of our initial inspection on 29 April 2015 the practice was placed into special measures. Inspections undertaken on 5 January 2016 and 20 October 2016 were intended to establish whether or not the practice had made sufficient improvement to enable them to be taken out of special measures. The practice remained in special measures after the inspection conducted on 5 January 2016. We found that the practice had not made sufficient improvement at our inspection on 20 October 2016 and is rated inadequate overall.

On the basis of our findings and the provider’s history of non-compliance we served a notice to cancel the provider’s registration under section 17 (1) (c) of The Health and Social Care Act 2008 on the basis that the provider was not carrying out the regulated activities in accordance with the relevant requirements of the 2014 Regulations.

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

  • Risks to patients were not always assessed or well managed. For example the practice had not complied with the recommendations in their health and safety risk assessment and insufficient attention was paid to infection control.
  • The practice nurse was not administering medicines in line with legislation and one of the partners did not have adequate medical indemnity cover in place.
  • National patient survey scores were below national and local averages and some of these scores were lower than those at the time of previous inspections. However feedback obtained from patients during the inspection process indicated that most patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said that access had generally improved. However it was evident from speaking to staff that there were not always a sufficient number of staff to meet patient demand. Urgent appointments were available the same day but patients could not book appointments online.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and most staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was an effective system in place for reporting and recording significant events however there was no evidence that patient safety alerts were being acted upon.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the clinical training to provide them with the skills, knowledge and experience to deliver effective care and treatment. However some essential training had not been completed by all staff including basic life support, infection control, child safeguarding and information governance.

Had we not served a notice proposing to cancel the provider’s registration, we would have set out the following list of ‘musts’ for their action:

  • Put systems in place to ensure that valid Patient Group Directions are always in place for nursing staff administering medicines, that there are systems in place to monitor cervical screening samples and that clinical staff do not undertake consultations with patients without adequate professional indemnity insurance.

  • Ensure that all mandatory training is completed in accordance with current guidance.

  • Ensure that arrangements are in place to identified and mitigate against risks associated with infection control, health and safety and management of prescription pads and review arrangements around emergencies to ensure that all staff are trained, know how to operate emergency equipment and that all emergency medicines are secure and fit for purpose

  • Ensure that there are systems in place to take and record action in response to patient safety alerts.

The areas where we would have said the provider should make improvement are:

  • Ensure that all relevant staff are made aware of learning from significant events.

  • Continue work on improving the management of patients in accordance with local and national targets.

  • Give consideration to the style of complaint responses.

  • Ensure that all staff receive adequate supervision, that all clinical employees are appraised annually and continue to work on improving staff morale and ensure that all staff are given adequate support.

  • Put systems in place to improve the identification of and support offered to carers.

  • Consider reviewing the level of staffing at the practice.

  • Continue with action to engage with patients and address areas of concern or dissatisfaction raised in the national patient survey.

  • Enable patients to book appointments online.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

5 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Falmouth Road Group Practice on 5 January 2016. Overall, improvements had been made and the practice is rated as requires improvement.

Our previous comprehensive inspection of the practice was carried out on 29 April 2015. Breaches of legal requirements were found. The practice was rated as inadequate for safe, caring , responsive and well-led and requires improvement for effective. All population groups were rated as inadequate due to the concerns found in safe, caring, responsive and well led. The overall rating from this inspection in April 2015 was inadequate and the practice was placed into special measures for six months following publication of the report on 2 July 2015. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Falmouth Road Group Practice on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(2)(c)(d)(e)(g)(h), Safe care and treatment; regulation 13(1)(2), Safeguarding service users from abuse and improper treatment and regulation 17(1)(2)(b)(e), Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The inspection carried out on 5 January 2016 found that the practice had made improvements and they were meeting the legal requirements that were previously breached. However we identified two breaches of regulations on this inspection as some areas still required improvemetns to be made.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • There was an improved system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment and personnel checks.
  • Data showed patient outcomes were low compared to the locality and nationally. Although data was low, performance information was not recorded correctly on the patient electronic record system.
  • Audits had been carried out, and we saw some evidence that audits were driving improvements in the service to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However patient survey data indicated that not all patients felt cared for, supported and listened to.
  • The appointment system had improved, however patients said they found it difficult to make an appointment and appointments were frequently delayed.
  • Urgent appointments were available the same day but some patients requiring emergency appointments experienced delays.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available and easy to understand.
  • The practice had a number of policies and procedures to govern activity, but they were not always easy to find.
  • The practice had established a formal Patient Participation Group and had started to put systems in place to gather patient feedback.
  • There was an improved leadership structure, and improved lines of communication, however staff still did not always feel valued and supported.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

  • Ensure that the practice keeps up to date and accurate personnel information for all staff working in the practice, including locum staff, contracted and self-employed staff, such as evidence of professional registration, professional indemnity, qualifications and a criminal records check.

  • Improve effectiveness of governance systems to ensure that policies and procedures, safety, risks, complaints, staffing records, training, quality and performance are clearly and accurately recorded and monitored and drive improvements in the practice.

  • Ensure that staff and patient feedback is sought and acted on to assist in the development of the service.

In addition the provider should:

  • Improve practice systems to support carers, including a carers register and providing adequate information and signposting.
  • Improve access to appointments, including telephone access and access for those requiring urgent or emergency appointments.
  • Consider installing a hearing loop.
  • Ensure that the use of appropriate coding on the patient record system improves accuracy of the practice’s performance data and ensures that patients are monitored more effectively.
  • Establish ways to ensure that staff feel motivated, valued and supported by the partners in the practice.

I confirm that this practice has improved sufficiently to be rated ‘Requires improvement’ overall. This service was placed in special measures on 2 July 2015. Although a number of concerns have been addressed and improvements have been made by the practice, there remains a rating of inadequate for one key question. Therefore, the practice is to remain in special measures for a further six months to ensure that they continue to make improvements. The service will be kept under review and another inspection will be conducted within six months. Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

29 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Falmouth Road Group Practice on 29 April 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, caring, responsive and well-led services. It was also inadequate for providing services for older people, people with long-term conditions, families, children and young people, people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia). The practice was found to require improvement for providing effective services.

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

  • Patients were generally positive about their interactions with staff and said they were treated with compassion and dignity, however a number of patients reported they would not recommend the practice.
  • Significant events were reported and there was some evidence of learning and communication with staff. However some staff were not clear about the process for reporting incidents, near misses and concerns.
  • Data showed patient outcomes were mostly at or below the average for the locality. Although two audits had been carried out, with some impact on patient outcomes, we saw no evidence that audits were driving improvement in performance long term.
  • Patients were at risk of harm because not all systems and processes were in place to keep them safe. For example, safeguarding and chaperoning procedures were not robust, full recruitment checks on staff had not been undertaken prior to their employment and we identified some concerns with infection control practice, medicines management and risk management.
  • The practice had received a number of complaints that were not always responded to in a timely manner.
  • Patients had to walk into the surgery to book a same day appointment. Patients said that they frequently had to wait a long time for urgent and non-urgent appointments due to the current appointment system.
  • The practice had a number of policies and procedures to govern activity, but policies were not easily accessible to staff. The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings.
  • The leadership structure was not always evident and the practice had insufficient management and strategic capacity.
  • The practice had not proactively sought feedback from staff or patients.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Review systems and process for safeguarding people from abuse including safeguarding children training for all staff, safeguarding adult training for identified staff and transparent safeguarding processes for staff to follow.
  • Ensure that staff performing chaperoning duties are able to safely carry out this role by providing chaperone training, a chaperoning policy and criminal records checks for all staff undertaking chaperoning duties where indicated.
  • Improve medicines management processes to ensure adequate monitoring of all medicines, including disposal of expired medications.
  • Ensure infection control procedures are robust by undertaking infection control and cleaning audits as required and providing infection control training for all staff.
  • Ensure that fire risk assessments and health and safety assessments are carried out and updated as required.
  • Ensure that the practice recruitment policy is updated and followed so necessary recruitment checks are recorded for all new employees.
  • Ensure all clinical and non-clinical staff employed by the practice receive regular mandatory training appropriate to their role, including basic life support and fire training.
  • Review and improve access to appointments for all patients and reduce waiting times for appointments.
  • Ensure complaints procedures are clear and accessible to patients.
  • Ensure adequate governance arrangements are in place to assist day to day management and strategic planning of the practice.
  • Ensure practice policies contain adequate detail and are easily accessible to all staff.
  • Ensure all staff receive an annual appraisal.

In addition the provider should:

  • Ensure there is a process to routinely cascade patient safety alerts and discuss the impact of these with all staff.
  • Keep a log of risks identified through practice risk assessments.
  • Ensure there is a robust process by which adequate staffing levels can be maintained.
  • Keep adequate and accessible staff training records and updated staff files.
  • Ensure care planning is completed for all appropriate patients with long term conditions, including dementia and mental health.
  • Complete patient surveys to identify areas to improve and use feedback to address practice issues.
  • Gather feedback from staff regarding practice performance and have a process for staff to be able to raise concerns.
  • Ensure the practice monitors performance through benchmarking and identifies needs of the population so service improvements can be targeted.
  • Ensure clinical audits demonstrate completed audit cycles to show improved outcomes for patients.
  • Ensure practice performance data is accurate by routine and appropriate use of the electronic patient record system.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice