London Street Surgery

We carried out an announced comprehensive inspection at London Street Surgery in April 2022. The overall rating for the practice was inadequate, specifically inadequate for the provision of safe and well-led services, requires improvement for effective services and good for caring and responsive services. We used our enforcement powers to take action against the breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 including issuing two warning notices. We placed the practice in special measures to enable the practice to improve.

We carried out an announced focused inspection in September 2022 to determine if the breaches of regulations had been addressed following the inspection in April 2022 but did not provide a new rating. Whilst improvements had been made in relation to the safe provision of services at the last inspection, there were still issues which constituted a new and continued breach of regulations.

At this announced focused inspection carried out on 6 December 2022, we found significant improvements had been made to the provision of care and treatment. However, there remains a continued breach of regulation. Following this inspection, we have provided a new overall rating of Requires improvement and the key questions have been rated as:

Safe – Requires improvement

Effective – Requires improvement

Caring – not inspected, rating of good carried forward from previous inspection

Responsive – not inspected, rating of good carried forward from previous inspection

Well-led – Requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for London Street 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 a previous inspection.

This was a focused inspection which included the key questions safe, effective and well-led and specific questions from responsive to find out whether patients could access services effectively and in a timely manner.

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 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 (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 short site visit.
• Speaking to members of the patient participation group

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 rated this practice Requires improvement for providing safe services because:

• The practice did not have a process in place to ensure staff had received the appropriate vaccinations to keep themselves and patients safe.
• The practice did not always act in response to safety alerts.
• Patient Specific Directions were not in place for staff giving vaccines where required.
• Prescription stationery security was not sufficient.

We rated this practice Requires improvement for providing effective services because:

• The practice did not have an effective process in place to encourage eligible patients to attend cervical screening appointments.
• The practice did not have a programme of learning and development for staff.
• Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions were not recorded accurately and were not reviewed.

We rated this practice Requires improvement for providing well-led services because:

• Quality assurance processes were not always effective in identifying issues and improving services.
• Governance systems and processes were not always effective.
• The system for the management of risks was not always effective.

We also found that:

• The practice had taken action following previous inspection to ensure patients were receiving appropriate monitoring and review.
• The practice had recruited and upskilled staff to increase its capacity to deal with patients.
• The provider recognised the importance of their Patient Participation Group and had re-started meetings following a pause during the COVID-19 pandemic.
• 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 focused on person-centre care.
• The practice had reviewed their appointment booking system and implemented changes they hoped would lead to an increase in availability.

We found 1 breach of regulation. The provider must:

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

Additionally, the provider should:

• Take steps to improve the update of cervical screening
• Improve the written recording of reviewing staff competencies.
• Take steps to implement a programme of targeted quality improvement.
• Take steps to review each staff role and ensure staff have completed all the necessary training.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services