Parson Drove Surgery

We carried out an announced comprehensive inspection at Parson Drove Surgery on 2 January 2024.

Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring – Requires Improvement

Responsive – Requires Improvement

Well-led - Inadequate

Following our previous inspection in 2016, the practice was rated as good overall.

At this inspection, we found that those areas previously regarded as good declined significantly. Furthermore, clinical and other concerns were found The practice is therefore now rated inadequate for providing safe, effective, well-led services and requires improvement for caring and responsive services.

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

Why we carried out this inspection

We carried out this inspection to follow up on patient safety concerns escalated to us.

How we carried out the inspection

This inspection was carried out in a way that enabled us to spend a minimum amount of time on site.

• Conducting staff interviews.
• Completing clinical searches on the practice’s patient records system remotely (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.

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 found that:

• Ineffective governance systems were in place and there were missing risk assessments and processes that are required by legislation to ensure a safe working environment.
• The provider was unable to demonstrate that they had taken action to address the poor satisfaction of patients who responded to the GP patient survey data or completed internal surveys to address the poor satisfaction expressed by patients. Furthermore, we saw that there was a decline in patient satisfaction over time in previous surveys and there was no system in place to address this.
• They were unable to demonstrate that any actions had been taken to record, address, or learn from complaints and significant events.
• The provider was unable to demonstrate that safe systems or practices were in place or working effectively regarding medicines management, safeguarding, recruitment, or management of risks to patients or staff.
• Systems and processes were not working as intended, overseen effectively, or structured in a way that enabled the provider to fulfill their responsibilities to the practice population.
• Clinical and non-clinical leadership were unable to demonstrate adequate capacity to deliver safe services which had led to significant gaps throughout the service.

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.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• Ensure vulnerable patients are identified and properly supported.
• Embed strengthened risk management approaches to ensure the safety of patients is managed.
• Ensure patients are protected from abuse and improper treatment.
• Ensure all premises and equipment used by the service provider is fit for use.
• Maintain appropriate standards of hygiene for premises and equipment.

The provider should:

• Take steps to address low uptake in cervical screening.

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described.

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.

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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care