We carried out an announced inspection at Orchard Surgery on 14 June 2022. Overall, the practice is rated as inadequate.
Safe - Inadequate
Effective - Inadequate
Caring - Good
Responsive – Requires improvement
Well-led – Inadequate
Following our previous inspection on 29 April 2016, 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 Orchard Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection including a site visit and was carried out as concerns had been received by CQC.
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 short 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:
- The practice failed to demonstrate they delivered safe and effective care to all their patients.
- The practice systems and processes in place did not ensure good governance to protect patients and staff from the risk of harm.
- We found there was a lack of leadership and oversight from the provider to ensure services were delivered in a safe and effective way to patients.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
We found 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 to the breaches of regulations, the provider should:
- Reduce the backlog of patient records awaiting full summarising.
- Continue to encourage the uptake of cervical screening.
- Review the system and process to ensure all patients with a learning disability receive an annual review.
- Review and improve the opportunities for patients to access health checks.
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.
As a result of the findings from our inspection, as to non-compliance, the Commission decided to issue a 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 Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care