The Care Quality Commission
  • Doctor
  • GP practice

Regency Surgery

Overall: Good read more about inspection ratings

4 Old Steine, Brighton, East Sussex, BN1 1FZ (01273) 600103

Provided and run by:
Regency Surgery

All Inspections

20 June 2023 to 22 June 2023

During a routine inspection

We carried out an announced comprehensive inspection at Regency Surgery from 20 June 2023 to 22 June 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

We carried out an announced comprehensive inspection of Regency Surgery in June 2022. This was part of a random selection of services rated Good or Outstanding, to test the reliability of our new monitoring approach. At this inspection the practice was rated inadequate and placed in special measures. We issued two warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). We carried out an inspection in December 2022 and confirmed the provider was compliant with the warning notices. However, as there were some systems and processes that were still in progress or needed to be embedded, we issued a requirement notice for Regulation 17 (Good governance).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Regency Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was carried out to confirm whether the provider continued to meet the legal requirements of regulations and to ensure enough improvements had been made.

The focus of our inspection included:

  • All key questions
  • To follow up on breaches of regulation 17 (good governance)
  • Areas we said the provider should improve;
    - Complete all remedial actions as identified by the fire risk assessment.
    - Strengthen monitoring checks of emergency equipment to include the defibrillator kept at the neighbouring practice.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews on site and 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 staff questionnaire.
  • A 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 found that:

  • The provider had continued to make improvements since our last inspection and had fully addressed all of the areas of concern raised by our last inspections.
  • Risks to patients, staff and visitors were assessed, monitored and managed effectively. This included child and adult safeguarding processes, staffing including recruitment and supervision, medicines management, health and safety, and information governance.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way. The practice was committed to offering a flexible and accessible appointment system that met the patient needs.
  • Feedback from patients from the national GP patient survey was consistently higher than local and national averages.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • Staff were proud to work at the practice and happy with the level of support provided by their management team and each other. Staff told us they were given opportunities to develop and further their career.
  • The practice leaders demonstrated that one of their commitments was for the practice becoming an eco-friendly and sustainable practice.
  • Governance systems and processes had continued to improve, evolve and embed.

Whilst we found no breaches of regulations, the provider should:

  • Review systems and processes to improve uptake of child immunisation and cervical screening.

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

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 Health Care

6 December to 8 December 2022

During an inspection looking at part of the service

We carried out an announced inspection at Regency Surgery from 6 to 8 December 2022 to assess compliance against two warning notices. Regency Surgery is currently rated inadequate overall. This inspection was not rated and therefore the previous ratings remain unchanged.

We carried out an announced comprehensive inspection of Regency Surgery from 21 June to 29 June 2022. This was part of a random selection of services rated Good or Outstanding, to test the reliability of our new monitoring approach. At this inspection the practice was rated inadequate and placed in special measures. On 15 July 2022 we issued two warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Regency Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This focused inspection was carried out to confirm whether the provider was compliant with the warning notices issued in July 2022. This report only covers our findings in relation to the warning notices.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

Our inspection included:

  • Conducting staff interviews.
  • 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, which was reviewed remotely.
  • A 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.

At this inspection we found that improvements had been made and the provider was compliant with the two warning notices.

We found that:

  • The provider had made improvements since our last inspection. There were developing systems to assess, monitor and manage risks to patients, staff and visitors.

  • There were some systems and processes that were still in progress or needed to be embedded. This included; safeguarding governance arrangements, recruitment processes, staff immunisation records, and safety alerts. We also found the learning from significant events and complaints had not always been shared effectively with all staff.

  • The systems to ensure the appropriate and safe use of medicines had significantly improved, including those for high risk medicines and for patients with long term conditions.

  • Staff had the information they needed to deliver safe care and treatment.

  • The responsibilities, roles and systems of accountability to support good governance and management were being established.

  • There was compassionate, inclusive and effective leadership at all levels.

  • The provider was fully engaged and committed to completing and embedding improvement actions. They were committed to providing high quality and compassionate care to their patients.

Although the provider was compliant with the two warning notices, we found breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Additionally, the provider should:

  • Complete all remedial actions as identified by the fire risk assessment.
  • Strengthen monitoring checks of emergency equipment to include the defibrillator kept at the neighbouring practice.

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

21 June to 29 June 2022

During a routine inspection

We carried out an announced inspection at Regency Surgery from 21 June to 29 June 2022.

Overall, the practice is rated as Inadequate.

Safe – Inadequate

Effective – Requires improvement

Caring - not inspected (Good, carried over)

Responsive – inspected, access questions only (Good, carried over)

Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Regency Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good or Outstanding, to test the reliability of our new monitoring approach. This inspection was a focused inspection that included the following key questions:

  • Safe
  • Effective
  • Well-led

During this inspection we also considered the management of access to appointments.

We carried forward ratings for caring and responsive from previous inspections, as the information we held did not indicate any change to ratings.

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 site visit
  • A staff questionnaire.

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:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • Risks to patients, staff and visitors were not always assessed, monitored or managed in an effective manner. This included child and adult safeguarding processes, staffing including recruitment and supervision, medicines management, health and safety, and information governance.
  • There was little evidence that all incidents, concerns, or near misses were consistently recorded and that opportunities for learning and quality improvement were identified.
  • The way the practice was led and managed did not promote the delivery of high-quality, person-centre care.
  • Governance systems and processes were not established and operating effectively.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • Staff told us they were happy with the level of support provided by their management team and each other. Staff told us they were given opportunities to develop and further their career.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • 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 their duties.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

Additionally, the provider should:

  • Review systems and processes to improve uptake of child immunisation and cervical screening.
  • Review the frequency of basic life support training for all staff.
  • Maintain records of completed and signed staff induction checklists
  • Continue to review and implement systems and processes to comply with the requirements of duty of candour.

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 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.

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

24 November 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

The practice was rated good overall and is now rated good for providing safe services.

We carried out an announced comprehensive inspection of this practice on 26 July 2016. A breach of legal requirements was found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 24 November 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

During our previous inspection on 26 July 2016 we found the following area where the practice must improve:

  • Adhere to the national requirements and the practice policy relating to the storage and disposal of controlled drugs.

Our previous report also highlighted the following areas where the practice should improve:

  • Ensure all staff receive appropriate training on the Mental Capacity Act 2005.

  • Ensure all staff are trained to the appropriate level for safeguarding children.

  • Increase the numbers of patients who attend national screening programmes for bowel and breast cancer screening.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

During the inspection on 24 November 2016 we found:

  • The practice had adequate policies and systems in place to ensure adherence to the national requirements for the storage and disposal of controlled drugs.

We also found in relation to the areas where the practice should improve:

  • All staff had appropriate understanding and training in the Mental Capacity Act 2005.

  • All staff were trained to the appropriate level for safeguarding children.

  • The practice showed us their action plan to increase the number of patients who attend screening programmes for bowel and breast cancer screening. This included putting posters and leaflets in the waiting room. The GPs told us that they now opportunistically reminded eligible patients of the benefits of screening during consultations.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Regency Surgery on 26 July 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were not always assessed and well managed for example in relation to storage and disposal of controlled medicines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However not all staff had received formal training on the Mental Capacity Act 2005. Not all nursing staff had received the appropriate level of training on safeguarding children.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt well 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.

We saw one area of outstanding practice:

  • Over 2% of the patients registered at the practice were human immunodeficiency virus (HIV) positive patients and all of these patients were offered annual reviews. The GPs had received specific training so that they were able to support patients with HIV who were also opiate dependent and prescribe appropriate medicines. A specialist substance misuse nurse visited the practice once every two weeks and worked collaboratively with the practice to maintain the health of this patient group.

The areas where the provider must make improvements are:

  • Adhere to the national requirements and the practice policy relating to the storage and disposal of controlled drugs.

The areas where the provider should make improvements are:

  • Ensure all staff receive appropriate training on the Mental Capacity Act 2005.

  • Ensure all staff are trained to the appropriate level for safeguarding children.

  • Increase the numbers of patients who attend national screening programmes for bowel and breast cancer screening.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 May 2014

During a routine inspection

Regency Surgery provides primary medical services from Monday to Friday for patients living in central Brighton. The practice is open from 8.30am until 6.30pm Monday to Friday. On Tuesdays the practice remains open until 7pm to accommodate those patients who work. Due to patient feedback the practice remains open during the lunch period. At the time of the inspection the practice had a patient list of just over 4,000.

On the day of the inspection we spoke with 14 patients, five administrative staff members and three members of clinical staff. This included the two GP partners, the practice nurse and the practice manager. We gained the views of the virtual patient participation group (PPG) via e-mail and asked patients for their views through comment cards left at the practice.

Patients we spoke with were complimentary about the service they received and told us they were able to access the service when needed. They described how they felt respected, cared for and were given appropriate information. We saw the results of a recent patient survey which showed patients were pleased with the service they received and would recommend the practice to family and friends.

We saw the practice had links with other healthcare services. For example, we saw links to the mental health service, who provided counsellors to the practice three times a week.

We toured the practice and found the non-clinical and clinical rooms to be clean, tidy and free from clutter. A member of the clinical team was the appointed infection control lead and was responsible for overseeing infection control at the practice. We saw evidence of an infection control audit completed in May 2014.

Staff told us that they found the leadership team approachable and there was an open door culture. We saw that the practice regularly reviewed staff performance at formal annual appraisal meetings. There were regular meetings within the practice where staff were able to voice their views.

We noted that mandatory training for staff was out of date. However this had been recognised by the practice and plans had been put into place to ensure that all staff were able to complete training necessary for their role before the end of the year.