Fronks Road Surgery

We carried out an unannounced inspection at Fronks Road Surgery on 01 August 2022 Overall, the practice is rated as Inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective - Inadequate

Caring - Requires Improvement

Responsive - Requires Improvement

Well-led - Inadequate

Following our previous inspection on 31 October 2017, the practice was rated Good overall and for all key questions:

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

Why we carried out this inspection

This was a focused unannounced inspection to follow-up on areas of concern received by the Care Quality Commission. Once on site, we made the decision to carry out a comprehensive inspection due to further concerns identified.

This included the key questions:

• Are services safe?
• Are services effective?
• Are services Caring?
• Are services Responsive?
• Are services well-led?

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 by three inspectors and a GP specialist advisor in a way which enabled us to spend a minimum amount of time on site.

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

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:

• There was a lack of clinical and managerial leadership, governance and oversight at the practice. This had led to the failure of safe, effective, and well-led care and treatment being delivered to all patients.
• Safeguarding systems and process did not keep people safe and safeguarded from abuse.
• Appropriate standards of cleanliness and hygiene were not met.
• We found systems and processes did not to identify and mitigate risks to staff and patients. There was a lack of evidence to demonstrate that risks were mitigated.
• Medicines management processes did not demonstrate the proper and safe management of medicines.
• The practice was unable to provide evidence of recruitment or staff induction to ensure safe processes where in place.
• Systems, policies and processes had not been monitored or reviewed, this included the monitoring of the practice service delivery, and staff competency.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. However, the service was still providing a restricted service to patients since the COVID-19 pandemic
• Complaints were not used to improve the quality of care or handled in a timely manner.
• We found the practice had failed to submit an unexpected death notification to the Care Quality Commission.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Since the inspection the practice has received support from the Integrated Care Board and begun a programme of improvement. However, these new systems and processes need to be fully implemented, embedded and monitored to ensure they are sustained and services are delivered safely and effectively.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Continue to encourage patients to attend for childhood immunisations.
• Continue to encourage patients to attend for cervical cancer screening.

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

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.

As a result of the findings from our inspection, with regard to non-compliance, but more seriously, the risk to patients’ life, health and wellbeing, the Commission decided to issue an urgent notice of decision to impose conditions on the provider’s CQC registration. For further information see the enforcement section of this report.

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