Archived: Hounsfield Surgery

We carried out an announced focussed inspection of Hounsfield Surgery on 22 January 2020. This inspection was undertaken to follow up on breaches of regulations which had been identified at our previous inspection in October 2019 in relation to safe care and treatment and good governance, therefore the practice was not rated at this inspection.

The warning notices that we issued in October 2019 required the practice to achieve compliance with the regulations by 29 November 2019.

The practice is currently rated as Inadequate which remains unchanged until we undertake a full comprehensive inspection of the practice.

Previous reports for this provider can be accessed on our website at www.cqc.org.uk.

At this inspection we found that the requirements of the warning notices had been fully met.

Our key findings across the areas that we inspected for this focussed inspection were as follows:

• Safeguarding systems had been improved to keep patients safe.
• Staff checks were taking place which included pre-employment, immunisation records and professional registration.
• Systems to keep the premises safe and clean had been improved.
• Care records contained appropriate detail to keep patients safe.
• Medicines were now safely managed at the practice.
• Systems for reporting and learning from significant events and acting upon safety alerts were effective.
• Completed audits contained actions and timescales where appropriate.
• Staff training and appraisal records had improved.
• Comprehensive complaints processes were now in place.
• Policies and procedures were now easily accessible to staff and included duty of candour arrangements.

Details of our findings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced focused inspection at Hounsfield Surgery on 10 October 2019 as part of our inspection programme.

The service was previously inspected in July 2015 and was rated Good overall at that inspection.

We carried out an inspection of this service as we believed there may have been a change in its overall rating since our previous inspection.

Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

• Effective
• Caring
• Responsive
• Well-led

However, due to findings during the inspection visit we also added the key question of:

• Safe

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 rated the practice as inadequate for providing safe services because:

• There were insufficient systems for safeguarding children and adults.
• Appropriate recruitment checks had not been undertaken before employing new staff.
• Staff immunisation status was not fully monitored.
• The practice did not have clear systems in place to ensure staff maintained their professional registration.
• Fire drills and fire training had not been completed by all staff.
• No risk assessments for the storage of liquid nitrogen or oxygen were available to mitigate the risk of storing hazardous materials.
• Processes to minimise the risk of infection were not always followed.
• Medicines were not always safely managed and there was a lack of clinical oversight of the dispensary.
• The practice did not learn and make improvements when things did not go well.
• Safety alerts were not always received and acted on appropriately.

We rated the practice as inadequate for providing well-led services because:

• The delivery of high-quality care was not assured by the leadership, governance or culture in place.

We rated the practice as Requires Improvement for providing effective services because:

• The clinical audit process did not always identify actions or timescales for actions to address areas of shortcoming found by audits.
• There was no effective system for monitoring or recording staff training and not all staff received regular appraisals.

These areas affected all population groups so we rated all population groups as Requires Improvement.

We rated the practice as Good for providing caring services because:

• Staff treated patients with kindness and respect and involved them in decisions about their care. Patients were very positive regarding the quality of care they received from practice staff.

We rated the practice as Good for providing responsive services because:

• The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure patients are protected from abuse and improper treatment.
• 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 the duties.
• Act in accordance with the Duty of Candour.

(Please see the specific details on action required at the end of this report).

The area where the provider should make improvements is:

• Improve complaints information available to patients and review the practice complaints process.

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.

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