We carried out a review of the data available to us about The Upstairs Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Upstairs Surgery, you can give feedback on this service.
We carried out an announced review of The Upstairs Surgery on 23 August 2021.
Following our previous comprehensive inspection on 22 July 2019, the practice was rated as good overall and for all key questions, except for the safe key question which was rated as requires improvement.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Upstairs Surgery on our website at www.cqc.org.uk.
This was a focused review of information (without undertaking a site visit) to follow up on the safe key question.
We based our judgement of the quality of care at this service on a combination of:
We have rated the practice as good overall.
We rated the practice as good for providing safe services because:
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
This practice is rated as Good overall. (Previous rating January 2019 – Requires Improvement)
The key questions are rated as:
Are services safe? – Require Improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We undertook this comprehensive inspection on 22 July 2019, to check whether improvements have been made since our previous inspection. Because of the concerns found at that inspection, we issued requirement notices for breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
At this inspection we found:
•The practice did not have suitable safety systems and processes in place in relation maintaining and sharing accurate safeguarding information.
Recruitment arrangements did not fully comply with published guidance in relation to ensuring appropriate staff vaccinations were completed for healthcare workers.
•The practice had made improvements in the management of patients with long-term conditions, due to the recruitment of additional nursing staff.
•There were gaps in the monitoring and review of clinical decisions of a non-medical prescriber.
•The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
•The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
•Staff involved and treated patients with compassion, kindness, dignity and respect.
•The practice had made improvements to access to care and treatment through the provision of additional clinical staff appointments.
•in response to findings at our previous inspection, the practice now had systems in place for reviewing performance and setting priorities to enable them to deliver high quality, sustainable care.
However, we found the provider must still make improvements as they are in breach of regulations and:
•Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
This practice is rated as requires improvement overall. (Previous rating March 2018 – Requires Improvement)
The key questions are rated as:
Are services safe? – Require Improvement
Are services effective? – Require Improvement
Are services caring? – Require Improvement
Are services responsive? – Require Improvement
Are services well-led? - Require Improvement
We undertook this comprehensive inspection on 6 November 2018 to follow up, but not limited to, whether the improvements had been sustained. This followed a series of inspections dating back to June 2016 where the practice has been rated requires improvement and inadequate and had previously been placed in special measures.
In March 2018 the practice was rated requires improvement overall with a rating of inadequate for providing safe services. We undertook a focused follow up inspection on 26 July 2018 to check that the practice had addressed the issues in the warning notices we issued in March 2018 and found that they had met the legal requirements. The full comprehensive report for the 12 March 2018 inspection can be found on our website at: http://www.cqc.org.uk/location/1-609934909
At this inspection although some improvements have been noted, we were not assured that the leadership had the skills to improve sufficiently to deliver high-quality, sustainable care.
At this inspection we found:
•The practice did not have suitable procedures in place for managing staff absences
•Patients with long-term conditions did not always receive a structured annual review to check their health
•The GPs did not work with other health and care professionals to deliver a coordinated package of care.
•The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
•The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
•Staff involved and treated patients with compassion, kindness, dignity and respect.
•Patients were not always able to access care and treatment from the practice within an acceptable timescale for their needs.
•There were no systems in place for reviewing performance and ensuring there is a strategy with priorities to enable them to deliver high quality, sustainable care.
The areas where the provider must make improvements as they are in breach of regulations are:
•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.
The areas where the provider should make improvements are:
• Review and asses the need to have written material in other languages given the demographics of the practice patient population.
•Continue to review patient’s feedback in relation to accessing appointments and waiting times and see what further improvements can be made.
•Consider changing the days meetings are held to accommodate the practice nursing team.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Hamilton-Smith and Partners on 12 March 2018. Breaches of legal requirement were found in relation to patient safety. We issued the practice with a Warning Notice for Regulation 12, Safe care and treatment requiring them to achieve compliance with the regulation by 30 April 2018. We found that patients were at risk of serious harm because the provider had not ensured those on high risk medicines were monitored in line with national guidance.
We undertook a focused follow up inspection on 26 July 2018 to check that the practice had addressed the issues in the Warning Notice and now met the legal requirements. This report only covers our findings in relation to those requirements. At the inspection, we found that the requirements of the Warning Notice had been met satisfactorily. Our key findings across the areas we inspected for this focused inspection were as follows:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
This practice is rated as requires improvement. (Previous inspection June 2017 – Inadequate)
The key questions are rated as:
Are services safe? – Inadequate
Are services effective? – Requires improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement.
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires improvement.
People with long-term conditions – Requires improvement.
Families, children and young people – Requires improvement.
Working age people (including those recently retired and students – Requires improvement.
People whose circumstances may make them vulnerable – Requires improvement.
People experiencing poor mental health (including people with dementia) - Requires improvement.
We carried out a comprehensive inspection of this service under Section 60 of the Health and Social Care Act 2008 on 5 May and 16 June 2016 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Health and Social Care Act 2014. Breaches of legal requirements were found and requirement notices issued in relation to patient safety, fit and proper persons employed and staffing. The full comprehensive report can be found on our website at: http://www.cqc.org.uk/sites/default/files/new_reports/AAAF1838.pdf
As a result, we undertook a comprehensive inspection on 5 June 2017 to follow up, but not limited to, whether action had been taken to address the breaches outlined in the notices as well as to look at the overall quality of the service. At this inspection we found insufficient improvements had been made which resulted in inadequate ratings for safe, effective and well led and requires improvement for caring and responsive. Overall the practice was rated inadequate. We issued warning notices for breaches of Regulation 12 Safe care and treatment and Regulation17 good governance and the practice was placed into special measures for a period of six months. We undertook a focused follow up inspection on 17 October 2017 to check that the practice had addressed the issues in the warning notices and found that they had met the legal requirements. The full comprehensive report for the 5 June 2017 inspection can be found on our website at: http://www.cqc.org.uk/location/1-609934909
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 12 March 2018 February. Overall the practice is rated as requires improvement.
At this inspection we found:
The practice had systems to manage most risks so that safety incidents were less likely to happen.
There were no systems in place to monitor patients on high risk medicines such as lithium.
Care and treatment for those on high risk medicines were not delivered according to evidence- based guidelines and their effectiveness and appropriateness was not monitored appropriately.
There were systems and processes in place to keep patients safe and safeguarded from abuse.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Twenty two of the 24 completed patient Care Quality Commission comment cards we received were positive about the service experienced.
Complaints handling had improved since our last inspection, however better oversight was required to ensure all complaints are responded to in a timely manner.
The areas where the provider must make improvements as they are in breach of regulations are:
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.
The areas where the provider should make improvements are:
Record discussions of patient safety alerts.
Review and take action to improve the practice’s performance for the management of long term conditions such as diabetes and take step to address areas of high exception reporting, for example, depression.
Continue to initiate and arrange multi-disciplinary team meetings with other healthcare professionals.
Continue to review patient’s feedback in relation to telephone access and waiting times and see what further improvements can be made.
Consider changing the days meetings are held to accommodate the practice nursing team.
Consider introducing an induction pack for locum clinical staff.
The service was placed in special measures in August 2017. Insufficient improvements have been made such that there remains a rating of inadequate for providing safe services. The service remains in special measures and will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to 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.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Hamilton-Smith and Partners on 5 June 2017. Breaches of legal requirements were found in relation to patient safety and governance arrangements in the practice. We issued the practice with warning notices for Regulation 12, Safe care and treatment and 17, Good governance requiring them to achieve compliance with the regulation by 17 July 2017. We found that the provider was failing to provide care and treatment in a safe way for service users and did not have effective governance processes and systems in place to keep people safe.
We undertook a focused inspection on 17 October 2017 to check that the practice had addressed the issues in the Warning Notices and now met the legal requirements. This report only covers our findings in relation to those requirements. At the inspection, we found that the requirements of the Warning Notices had been met. Our key findings across the areas we inspected for this focused inspection were as follows:
The practice had updated several policies including safeguarding and complaints. Staff were now able to access policies on the computer shared drive and hard copies held in the practice manager’s office.
We found infection control audits were now undertaken and actions identified had been remedied.
There was a system in place for monitoring blank prescriptions.
Staff undertaking chaperoning duties now had records of Disclosure and Barring Service (DBS) checks in their staff records. The healthcare assistant (HCA) had received an enhanced DBS check.
We saw that the practice had replaced fabric curtains with disposable curtains.
Electrical safety checks had been carried out on portable equipment to ensure they were safe to use.
The arrangements for identifying, recording and managing risks had improved.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Hamilton-Smith and Partners Practice on 5 May and 16 June 2016 and rated the practice as requires improvement for the safe, effective, responsive and well-led key questions and good for caring. This led to an overall rating of requires improvement. Breaches of legal requirements were found and requirement notices were issued in relation to patient safety, fit and proper persons employed and staffing. The full comprehensive report can be found by selecting the ‘all reports’ link for Dr Hamilton-Smith and Partners Practice on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection which we undertook on 5 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 5 May and 16 June 2016. This report covers our findings in relation to those requirements. The overall rating from this visit was inadequate. Our key findings across all the areas we inspected were as follows:
There was a system in place for reporting and recording significant events; however the practice did not have a significant event/incident policy available on the day of inspection and staff we spoke with told us they would access the policy via the shared drive. When asked to access the policy, staff including the practice manager were not able to access the policy.
The practice had some systems, processes and practices in place to minimise risks to patient safety, but there were some gaps, for example, non-clinical staff had not completed training in safeguarding children.
The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions needed reviewing and strengthened to ensure patients safety. For example, learning from significant events were not always evident and electrical equipment were last tested in 2013.
Data from the Quality and Outcomes Framework showed patient outcomes were at or above the national average; however, the practice was below average for diabetes indicators.
Clinical audit received following the inspection demonstrated little quality improvement.
The practice had a mission statement which was underpinned by three visions and that was to provide the best possible clinical care and to give a high quality, courteous and efficient service.
Practice specific policies were generic, duplicated and should be available to all staff by way of hard copy or on the shared drive; however, we found these policies were not always readily available.
The areas where the provider must make improvements are:
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.
The areas where the provider should make improvements are:
Improve the current system in place to identify carers so that they can receive appropriate support available to them.
Improve communication with other health and social care professionals to understand and meet the range and complexity of patients’ needs and to assess and plan ongoing care and treatment.
Improve patients’ and their carers’ awareness of the translation/interpreting service.
Review ways in which communication with service users who have difficulty hearing can be improved.
This service was rated requires improvement after our previous inspection on 5 May and 16 June 2016. Insufficient improvements have been made which has resulted in inadequate ratings for safe, effective and well led. Therefore we are taking action in line with our enforcement procedures to issue Warning Notices under Regulations 12 and 17 as the majority of issues found previously in safe had not been addressed satisfactorily and the management team did not consistently demonstrate they had the capacity and capability to run the practice. 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration 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.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr Hamilton-Smith and Partners on 5 May and16 June 2016. Overall, the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvements are:
In addition the provider should:
Chief Inspector of General Practice
People said they were satisfied with the care and treatment they received and that it met their needs. Comments included 'they understand you', 'they take a holistic approach, not just looking at the issue you came in for' and 'it's very refreshing coming here. I'm impressed with the doctors'.
People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse from happening. People told us that they felt safe in the environment. The provider should note that measures should be put in place to ensure that all staff are able to identify the possibility of abuse and to respond appropriately.
There were systems in place to reduce the risk and spread of infection. People said they were satisfied with the standards of hygiene and cleanliness of the service. Comments included 'the surgery is clean, yes it is very clean' and 'I've seen the doctor washing his hands'.
People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. The provider took account of complaints and comments to improve the service.