Dudley Wood Surgery

We carried out an unannounced comprehensive inspection at Dudley Wood Surgery on 23 January 2020.

We undertook the inspection of this service following whistleblowing concerns received, regarding patient safety and the overall management of the service.

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 rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• Not all staff had received the appropriate level of safeguarding training, fire training or infection prevention and control training.
• There was a back-log of new patient records that had not been summarised. The practice was unable to give us reassurance that there was no safeguarding information held in these records.
• The system for monitoring and reviewing recruitment files needed strengthening as there was no overarching system to ensure this was monitored and reviewed in accordance with the regulations.
• The practice did not provide evidence they had oversight of all staff vaccinations in line with current Public Health England guidance.
• Disclosure and barring checks (DBS) had not been carried out for all staff, there were no risk assessments in place and the policy for completing risk assessments had not been reviewed.
• We found health and safety, fire risk assessment and security risk assessment had not been completed at the practice premises.
• There was no infection control audits completed.
• There was no effective induction for newly appointed staff.
• There was no effective approach to managing staff absences.
• There was no comprehensive recording of, or analysis of significant events, complaints or patient safety that would lead to practice improvements. There was no clear learning from these events.

We rated the practice as inadequate for providing effective services because:

• The practice’s uptake of cervical screening was below the 80% target rate; the practice were aware of this data but had no plan in place at the time of inspection to improve it.
• The practice’s uptake of childhood immunisations rates were below the national averages and action taken had not yet demonstrated improved outcomes.
• There was limited evidence of quality improvement activity.
• There were gaps in staff training and not all staff had completed training in safeguarding, fire safety, equality and diversity or infection prevention and control.
• We saw evidence that staff were working outside of their sphere of competence.
• The provider could not demonstrate they undertook regular appraisals and clinical supervision with staff.
• The practice was unable to show that some staff had the skills, knowledge and experience to carry out their roles.

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

• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care
• The practice was not able to demonstrate good governance or awareness of the risks or challenges they face.
• There were gaps in the practice’s governance systems and processes and the overall governance arrangements were ineffective.
• There was no clinical lead to oversee governance issues.
• The practice did not have a realistic strategy to provide high quality care.
• The practice had not implemented a clear and effective process for managing risks, issues and performance.
• The practice did not involve patients or staff in shaping the service.
• We saw limited evidence of learning and continuous improvement.

These areas affected all population groups so we rated all population groups as inadequate.

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

• 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 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 that there is sufficient numbers of suitably qualified, competent, skilled and experienced staff.

The areas where the provider should make improvements are:

• Ensure there is a comprehensive complaints system in place.
• Develop a strategy to address low childhood immunisations achievement rates.
• Develop a strategy to address low cervical smear achievement rates.

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.

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