Church Lane Surgery

We carried out an announced comprehensive inspection at Church Lane Surgery on 21 November 2019 part of our inspection programme.

An inspection had been carried out on 8 August 2018. At this inspection, the practice was rated as inadequate overall and inadequate for providing, safe, effective, caring, responsive and well-led services.

The practice was placed in special measures in October 2018 and a further focused inspection took place in December 2018. This inspection was not rated but we were satisfied that risks had been sufficiently reduced at that time.

An announced comprehensive inspection took place on 26 March 2019 to confirm that the practice had carried out their plan to meet the legal requirements in relation to breaches of regulations from previous inspections. The overall rating for the service was requires improvement, with a rating of good for providing safe services, requires improvement for providing effective, caring and well-led services and inadequate for providing responsive services. All of the population groups were rated as inadequate for providing responsive care.

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 requires improvement overall and inadequate for the population group long-term conditions.

We rated this practice as good for providing safe and well-led services because the practice provided care in a way that kept patients safe and protected them from avoidable harm. The leadership at the practice was committed to making improvements.

We rated the population group long-term conditions as inadequate for providing effective services because:

• The clinical outcome indicators were below local and national averages and there had not been sufficient improvement since the previous inspection.

We rated this practice as requires improvement for providing caring services because:

• Patient satisfaction in relation to the health professionals seen at appointments was below local and national averages. We acknowledged that the practice had seen this as a priority since the previous inspection and had carried out their own surveys to monitor performance. However, there had not been sufficient improvement since the last inspection.

We rated this practice as requires improvement for providing responsive services because:

• Patient satisfaction regarding making and accessing appointments was below local and national averages. We acknowledged the practice had made plans to improve since the previous inspection, but outcomes were still below local and national averages.

• This affected all of the population groups and so we rated them all as requires improvement for responsive services.

The areas where the practice must make improvements are:

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

The areas where the practice should make improvements are:

• Continue to improve the outcomes for people experiencing poor mental health (including people with dementia).

This service was placed in special measures in October 2018. We acknowledge the improvements made since the last inspection. However, insufficient improvements have been made such that there remains a rating of inadequate for patients with long-term conditions. The service will be kept under review and another inspection will be conducted within six months and if there is not enough improvement, we will review the position and consider whether there is a need to take further action.

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.

We carried out an announced comprehensive inspection at Church Lane Surgery on 26 March 2019 as part of our inspection programme.

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 previously carried out an announced comprehensive inspection at Church Lane Surgery on 8th August 2018 and the overall rating for the service was inadequate. We found that the practice was inadequate for providing safe, effective, caring, responsive and well led services. As a result, we issued a requirement notice for regulation 12, safe care and treatment and a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

The service was placed in special measures in October 2018. A further focused inspection was undertaken in December 2018, where we followed up concerns from the warning notice we had issued.

That re-inspection was not given a rating, but we were satisfied that risks had been sufficiently reduced at that time. This inspection was an announced comprehensive inspection carried out on 26th March 2019 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections.

We have rated this practice as requires improvement overall and inadequate for all population groups.

We rated this practice as requires improvement for providing effective services because two population groups are rated as requires improvement because:

• The clinical outcome indicators for 2017/2018 for people with long term conditions and those experiencing poor mental health was below local and national averages. Although the unverified data from 2018/2019 showed an upward trend for those experiencing poor mental health these figures were still below the national averages.

We rated this practice as requires improvement for providing caring services because:

• Patient satisfaction in relation to the health professionals seen at appointments was below local and national averages.

We rated this practice as inadequate for providing responsive services because:

• Patient satisfaction regarding making and accessing appointments was below local and national averages. Although we had acknowledged that the practice had carried out its own patient survey relating to access of appointments and had introduced improvements these still needed to be fully reviewed for their effectiveness.

These areas affected all population groups, so we rated all population groups as inadequate for providing responsive services.

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

Although the practice had strengthened its governance structures, which were regularly reviewed, not all improvements had been actioned from the last inspection and although the service had a plan for recruitment activities this had not produced significant improvements on the day of the inspection and therefore we were not assured that improvements could be sustained over time.

We rated this practice as good for providing safe services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.

We rated the population groups older people, families, children and young people, working age people and people who were vulnerable in the effective domain as good because we were satisfied that effective services were being provided.

The areas where the practice must make improvements are:

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

The areas where the practice should make improvements are

• Continue to review historic safety alerts based on risk.
• Continue to review and strengthen governance structures and recruitment issues.

This service was placed in special measures in October 2018. We acknowledge the improvements made since the last inspection. However, insufficient improvements have been made such that there remains a rating of inadequate in the responsive domain. The service will be kept under review and another inspection will be conducted within six months and if there is not enough improvement, we will review the position and consider whether there is a need to take further action.

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.

Church Lane Surgery was previously inspected in August 2018 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, caring responsive and well-led services. As a result, we issued a requirement notice for regulation 12, safe care and treatment and a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

We carried out an announced focused inspection at Church Lane Surgery on 19 December 2018. The focused inspection was to review whether the provider had made improvements and was compliant with the warning notice. We also looked at the governance arrangements and the leadership of the practice. The practice was not rated at this inspection.

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.

This was an unrated focused inspection.

We previously found that:

• There were not clear responsibilities, roles and systems of accountability to support good governance and management.
• The practice system to ensure safeguarding was managed effectively needed to be improved for example they did not hold accurate registers of patients where concerns had been raised or hold regular safeguarding meetings with external agencies to share concerns.
• The systems for managing correspondence, referrals, pathology results and patient notes was ineffective and did not ensure these were managed in a timely manner.
• The system for monitoring uncollected prescriptions was not effective.
• Outcomes for the Quality and Outcomes Framework were significantly lower than local and national averages. Not all patients were receiving annual monitoring in a timely manner.
• There were limited structures, processes or systems at the practice that identified clinical accountability. There was a lack of clinical and non-clinical meetings to discuss issues, learning or to receive feedback from staff.
• There was a lack of system in place to demonstrate review of staff competencies.
• You were unable to demonstrate that staff receive appropriate appraisal to enable you to be assured that staff are able to carry out the duties for which they are employed.
• There was some evidence of clinical audit, however this was limited and was not used as a tool to drive improvements in the practice.

At this inspection we found that:

• The practice had established clearer responsibilities, roles and systems of accountability to support good governance and management. Staff we spoke with on the day of the inspection told us leaders were approachable and responsive to their needs.
• The practice had strengthened their system to ensure safeguarding was managed effectively. They had implemented a system to review registers of patients’ where concerns had been raised to ensure they were accurate. The practice had established systems to share and monitor safeguarding concerns with external agencies.
• The systems for managing correspondence, referrals, pathology results and patient notes had improved, we found these were routinely managed in a timely manner.
• The practice had implemented a system for monitoring uncollected prescriptions to ensure they were monitored effectively.Staff we spoke with on the day understood their roles and responsibilities to monitor uncollected prescriptions.
• The practice had created systems to monitor Outcomes for the Quality and Outcomes Framework performance however the practice told us it had not been possible to effectively implement these systems due to unplanned changes in the clinical workforce. Therefore, when were viewed unverified data from the first nine months of the year, we found there had not been an improvement in their quality outcomes. The practice was aware of their performance and the new leadership team had recently implemented revised action plan to improve this.
• There were structures, processes and systems at the practice that identified clinical accountability. The practice had implemented clinical and non-clinical meetings to discuss issues, learning and to receive feedback from staff. We reviewed meeting minutes and found that they were well attended and shared amongst all practice staff.
• There was a system in place to demonstrate review of staff competencies. Staff had received appropriate appraisal to ensure they were able to carry out the duties for which they were employed.
• The practice had implemented a plan to ensure clinical audits where carried out regularly and used as a tool to drive improvements in the practice.

Overall, we found that the practice had complied with the warning notice, however, further improvements were required to improve the monitoring of patients with health conditions that were subject to the Quality and Outcomes Framework.

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

• Improve systems and processes in place to monitor Quality and Outcomes Framework performance.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice