KEY:Information especially relating to Practice managers is in YellowInformation especially relating to GPs is in BlueInformation especially relating to Nurses is in GreenInformation especially relating to Admin/Reception staff is in PinkInformation especially relating to Partners is in GreyInformation for EVERYONE is in text coloured RED

Outcome 1: Respecting and involving people who use services

Minor

Five of the patients we spoke with said that while seeing the doctor in the consulting room,

they had sometimes been interrupted by a receptionist who had entered without knocking.

Two patients explained that they were embarrassed by this, while the other three said they

didn’t mind. We saw that there were clear signs on the doors to tell people to knock before

they enter the room.

When we spoke to reception staff, two said they had been told to knock and wait at the door

if they needed to enter. One said they had not had this guidance as they were new and their

induction training had been delayed. They agreed that occasionally they might need to enter

a consulting room during a consultation and did not wait to be invited in before entering.

They said the GPs in question had never challenged them about this behaviour. We spoke

to two GPs who agreed that they had not challenged the receptionist on the few occasions

this had happened. This meant that not all staff treated people with dignity and respected

their privacy.

Our judgement

The provider did not have suitable arrangements to respect the dignity and privacy of

patients. This was because staff did not treat patients with consideration and respect.

Moderate

The surgery was in a town with an ethnically diverse population, and had a significantly high

number of Pakistani people on its patient register. We spoke with a child who was

accompanying their mother. The child told us they had asked the reception staff to provide

information about the practice in their mother’s native language, as she did not speak

English. The child said they had asked for this three months previously but they had still not

received it. We noted that there was no information available in any language other than

1

English. There was also no process in place to enable translation or interpretation services

where these were required.

We asked the practice to show us evidence of information for its Pakistani patients in the

relevant languages, but the practice did not have this. This meant that some people would

not be able to make informed decisions about their treatment. During our inspection the

practice manager contacted a translation service to make sure that arrangements could be

made available for people using the service in the future.

Our judgement

Patients were not provided with appropriate information and support to understand the

treatment available to them. The provider did not have suitable arrangements to make

information about their care and treatment available in alternative languages.

Major

We spoke with three patients at the practice. They all told us that their GP had never

explained their treatment to them. One patient told us that the GP had said to them recently

“It is best if you don’t know”. Another patient told us they had asked for information about the

medication they had been prescribed and what it was for, but the GP said they didn’t have

time to explain it and that the person should “look it up on the web”. All three people said

they had never seen any information in the surgery that they could refer to for any health

matters.

We spoke to two GPs about this. They said they were “too busy” to provide this information.

They did not demonstrate their responsibilities to their patients in this respect. This meant

that the service was not providing essential information to people. There was a risk that

people would not understand the treatment and choices available to them.

Our judgement

People were not given information about their treatment options and were therefore unable

to make informed decisions about their treatment. Patients’ views and experiences were not

taken into account in the way the service was provided and delivered in relation to their care.

2

Outcome 2: Consent to care and treatment

Minor

We spoke to two patients who had attended the practice for treatment involving procedures.

Both patients confirmed that they were given information about the procedure before it was

carried out; this included follow-up treatments as well as what the procedure involved. We

spoke to two GPs who said that they would not go ahead with a procedure if they were not

confident the patient understood it and consented to it.

We looked at the records of six patients who needed to give consent to treatment. We asked

the practice manager what arrangements were in place for making sure that valid consent

was obtained from children. The practice manager explained that staff would always assess

the child’s ability to understand before going ahead with any treatment.

We looked at records of one 12-year-old child who had been referred to the hospital for a

consultation to discuss the possibilities of having a birthmark removed. There were notes on

the record that discussion had taken place with the child’s mother, but no evidence that the

child had been given the opportunity to discuss how they felt about the birth mark or having it

removed. One of the GPs said that they knew the hospital would always discuss such issues

with the child before any treatment was arranged. They therefore felt it was not essential at

this stage to explore the child’s view themselves. Given that the child was only 12 years old,

they were unsure whether treatment to remove the birthmark was possible and in any case

the child may change their mind. This meant the provider had not assessed whether the

young child had understood the care and treatment options available and was able to

provide valid consent themselves. Therefore, the provider could not ensure that they had

obtained people’s informed consent for care or treatment.

Our judgement

The provider did not have suitable arrangements in place to obtain, and act in accordance

with, the consent of patients in relation to the care and treatment provided for them.

Moderate

As part of our inspection we looked at the system in place for dealing with complaints and

comments made by people using the service. During our review of complaints, we found a

complaint that had been received that morning. The detail of the complaint indicated to us

that the patient had been unaware that there was a risk of infection following the surgical

3

procedure of a vasectomy. We asked to see consent policies used in the practice and found

these contained comprehensive and valid guidance for staff.

We asked both GPs on duty what information they provide to men wishing to arrange to

have a vasectomy at the surgery. Both GPs advised us that they don’t provide patients with

written information on this subject, but that they do advise patients about the most common

complications. We asked to see some records in relation to this procedure. Six records

reviewed demonstrated that a consent process had been followed but two sets of notes did

not confirm that the patient had been informed about the possible risk of infection or

haematoma following vasectomy. This meant that those patients could not give valid consent

because some of the recognised risks had not been properly explained.

Our judgement

The provider did not have suitable arrangements in place for obtaining, and acting in

accordance with, the consent of patients in relation to the care and treatment provided for

them.

Major

During our inspection we looked at records from a nurse-led baby vaccination clinic held at

the practice the previous day. In three records there was no evidence that consent was

obtained from a person who was lawfully able to consent on the child’s behalf before the

nurse administered the vaccination. We saw that two of these records referred to second

and third booster vaccinations. One eight-week-old baby had its first set of vaccinations

administered the previous day but we saw no record of any consent being obtained for this.

We spoke to the nurse responsible for the clinic. The nurse told us that the family’s au pair

had brought the baby in for their vaccinations. The nurse told us that as the au pair didn’t

speak any English, it was pointless asking her anything. The nurse said “I didn’t bother

explaining what vaccines I would be giving the baby or any effects these may cause as the

au pair wouldn’t have understood me.” We asked the nurse if they had asked if the baby was

fit and well before they had administered the vaccinations. The nurse told us, “Well she [the

au pair] held out the baby’s leg and the baby looked well, so I went ahead.” The nurse

confirmed they had made no attempt to contact either of the parents to verify consent or

inform them of the vaccines being given to the baby.

4

The practice manager told us the surgery did not have any records of the parents giving

consent for the baby to have these vaccines or of them being informed about the vaccines.

The manager told us that this was quite common in the practice, as there were many

families in the area with both parents working full-time and au pairs or nannies often brought

children in for vaccinations. The manager told us, “The families often make the appointment

so surely it’s implied they (the parents) have consented.” We asked the manager if they had

any record of which family member had made the appointment, how they had made it and

when. The manager confirmed they did not. This meant that the provider was not acting in

accordance with legal requirements to obtain consent.

Our judgement

The provider did not have suitable arrangements in place in relation to obtaining consent.

Where children were under 16 and not competent to consent to treatment, the provider did

not have suitable arrangements in place for obtaining valid consent from someone who was

lawfully able to consent on behalf of the child.

5

Outcome 4: Care and welfare of people who use services

Minor

We asked reception staff to tell us about how they would register a new patient at the

practice. They told us they would take the details of the new patient. Both receptionists told

us that they would not invite them to come in for a registration check up with the nurse. We

looked at the records of four new patients. None of the records we looked at included a

registration check before patients subsequently saw a GP. However, we were shown the

policy for registering new patients, which stated that staff should ask all new patients to have

a registration check up. This meant that the needs of new patients were not assessed.

Our judgement

The provider did not take proper steps to ensure that patients were protected against the

risks of receiving care or treatment that was inappropriate or unsafe. This was because new

patients’ individual needs were not assessed when they registered with the practice.

Moderate

We asked the practice manager about the monitoring and care of people who have been

discharged from hospital. We were shown the care records for four people who had recently

been discharged from hospital. From these, we saw that one person had been identified as

being at risk of deterioration through recurrent infections. The hospital discharge records

requested that the GP monitor the person’s condition on a regular basis to ensure their care

needs were met and to prevent their condition from worsening. However, we did not see any

evidence to support that this had occurred, or that processes were in place to follow up this

request.

We spoke with the GP and practice manager who confirmed this person had not been seen

since their discharge and that the GP had not carried out a risk assessment as to whether

follow-up was required. The records showed this person had been discharged from hospital

two weeks previously, and was therefore at risk as their condition had not been monitored.

Our judgement

The provider did not take steps to ensure the delivery of proper care. Patients were therefore

not adequately protected from the risk of inappropriate or unsafe care and treatment.

6

Major

We reviewed the resuscitation equipment available for staff to use if a patient’s condition

deteriorated rapidly. We reviewed the surgery’s emergency kit, which included a checklist

detailing precisely what items should be available at all times. The kit had a number of items

missing when compared with the checklist and staff were unclear as to what it should

contain. Some of the items, including intravenous medicines, had passed their expiry date by

over four weeks. This meant that people were at risk of not receiving appropriate treatment

because medication was out-of-date. We spoke to a member of staff who explained that

there was no formal process to check emergency equipment or medication.

Our judgement

The provider did not have procedures in place to maintain the resuscitation kit to be used for

a patient emergency.

7

Outcome 6: Cooperating with other providers

Minor

We spoke with two community nurses who worked closely with the provider. They stated that

they had difficulty in communicating with the provider when they had problems or queries

about particular patients. One said there were occasions when they had tried to contact the

duty doctor for support in relation to a patient, but the doctor had not returned their call for

several hours. In these circumstances the nurse had made other arrangements to meet the

person’s individual needs and therefore the impact on people’s care was not significant. The

receptionist told us it was difficult to contact the duty doctor because he was always in and

out of appointments. We spoke to the provider who confirmed that there was no process in

the practice for when the duty doctor would make themselves available to speak with

professionals from other services.

Our judgement

The provider did not have suitable arrangements in place to protect the health, welfare and

safety of patients in circumstances where responsibility for their care and treatment was

shared with others. This was because the provider had not made suitable arrangements to

work in cooperation with the duty doctor to ensure that appropriate care planning took place.

Moderate

We spoke with three professionals working in community services. They told us that referral

emails or forms were not completed and information from most of the GPs in the practice

was often minimal. They said that sometimes they were given just one word such as

‘anxiety’, or ‘backache’. They told us they found it impossible to prioritise assessments and

had to discuss each case from the beginning with the person the care related to.

Our judgement

People may not have received appropriate support as the provision of information to support

care planning and treatment with other providers was ineffective. The provider had not made

suitable arrangements to protect the health, safety and welfare of people where

responsibility for their care was shared or transferred to others.

Major

8

We found that the GP practice wasn't working effectively with its local GP out-of-hours

service, which was adversely affecting the treatment and care of patients outside surgery

hours. A locum GP working at the practice told us that they had received numerous

concerns from the local GP out-of-hours provider and relatives of deceased patients

receiving palliative care that the practice was not sharing appropriate and relevant

information about its patients. This included patients receiving palliative and end-of-life care

who needed care and treatment from well-informed doctors during the out-of-hours period.

There were examples where relatives of such patients had contacted the out-of-hours

service, but the service could not treat those patients effectively as they had no prior

information about their condition and the end-of-life treatment they were receiving.

Our judgement

The provider had not made suitable arrangements to protect the health, safety and welfare

of patients where responsibility for their care was shared or transferred to others. This was

because the GP practice wasn't working effectively with its local GP out-of-hours service.

9

Outcome 7: Safeguarding people who use services from abuse

Minor

All staff we spoke with were aware of the need to contact the local authority if they had

safeguarding concerns. The practice manager showed us the policy for the protection of

children and teenagers. There was no formal policy and procedure for the protection of

vulnerable adults. The lack of a policy could place adults at risk because there was no clear

system for reporting concerns and following up on action being taken to ensure that people

were protected.

Most, but not all staff were able to tell us about procedures relating to safeguarding

vulnerable adults. Staff said that they completed training in safeguarding but all said that the

focus of the training was on protecting children from abuse. This means that vulnerable

adults may not be adequately protected from the risk of abuse.

Our judgement

People were not protected against the risk of abuse because the provider did not have

suitable arrangements in place for reporting concerns, or sharing information, about

vulnerable adults who may be at risk of abuse.

Moderate

Child protection policies included contact details for the local safeguarding children team.

The adult protection policy was basic and stated that the safeguarding team for adults

should be contacted in line with multi-agency guidance. However, the multi-agency guidance

was not available. Some of the staff we spoke with were unsure about which procedures to

follow and they did not fully understand how to recognise signs of potential abuse.

Our judgement

People were not safeguarded against the risk of abuse. This was because the provider had

not made suitable arrangements to take reasonable steps to identify the possibility of abuse

and prevent it before it occurred, or by responding appropriately to any allegation of abuse.

Major

10

The provider of this walk-in centre had previously been involved in a serious case review but

had not taken any steps to respond to the recommendations of the review. A nurse

practitioner working at the centre had not identified a baby as being harmed and at risk of

future harm. The baby’s mother had brought it in with injuries twice over a three-day period.

The nurse had not appropriately identified the injuries as being non-accidental or identified

concerns about the injuries and their frequent presentation. As such, the nurse had not

referred the baby to the children’s social care team, which is the usual process for managing

such concerns. The day after the mother and baby had attended the walk-in centre, the baby

was admitted to hospital with life-threatening injuries and the hospital referred the case to

children’s social care.

The serious case review identified that the provider needed to train its staff to the

appropriate level and give additional training in identifying non-accidental injuries. The

review also recommended that the provider should improve its child protection policy,

provide information for staff on how to seek advice on child protection issues and update

information on how to refer children to children’s social care. The provider had not

responded to these recommendations. This meant that staff were unable to recognise abuse

and did not have clear procedures to manage alleged or suspected abuse.

Our judgement

Children were not protected from the risk of abuse. The provider had not made suitable

arrangements to ensure that they were safeguarded against the risk of abuse by taking

reasonable steps to identify the possibility of abuse and prevent it before it occurred, and by

responding appropriately to any allegation of abuse.

11

Outcome 8: Cleanliness and infection control

Minor

We were told that the practice used to carry out regular infection control audits, but these

had recently lapsed. This meant that systems to monitor the prevention and control of

infection in the practice were not being monitored. There was a designated lead person

responsible for infection control at the practice but they said that they were unclear what

their duties were and that they were not familiar with the Code of Practice for health and

adult social care on the prevention and control of infections and related guidance.

The practice manager said they asked for infection control advice if needed. While the staff

we spoke with were aware of the correct cleaning equipment to use, there were no cleaning

schedules in place and no guidance available on how to clean each area. This meant that

the arrangements at the practice for maintaining a clean environment were not sufficient to

prevent and control the risk of infection.

Our judgement

Without regular assessments of infection control risks and monitoring of compliance with the

Code of Practice, the provider could not be assured that people were protected from the risk

of acquiring a health care associated infection.

Moderate

The practice manager said he was the lead for infection prevention and control at the

practice, although he had not had specific recent training in infection control practices. We

saw evidence that the local PCT had last audited infection control at the practice two years

ago. Staff confirmed that no internal infection control audits had been undertaken since then,

although post-minor surgery infection rates were audited.

Parts of the practice were not kept clean and were not maintained in good condition. We

found that neither of the two foot-operated clinical waste bins in the treatment room worked

properly and there were broken tiles above a basin, presenting an infection risk. A couch

used for minor surgery for patients in the treatment room had tears in its vinyl covering. This

presented a risk of infection because the covers could not be cleaned effectively. The

disrepair to equipment and tiling meant that people were not fully protected from the risk of

infection because appropriate guidance had not been followed.

12

Our judgement

People were not cared for in a clean and hygienic environment. The provider was not

ensuring that people were protected against identifiable risks of acquiring a health care

associated infection. This was because the provider did not have effective systems in place

to assess the risk of and to prevent, detect and control the spread of such an infection.

Major

We found evidence that there were no effective systems in place to reduce the risk and

spread of infection. In the treatment room we saw that dressings and gloves used to prevent

the spread of infection during and following treatment were past their expiry date. We could

not find any dressings or gloves that were within their expiry date. When we spoke to the

doctor who performed treatments in the room they confirmed that the room and equipment

were used about once a month. This meant that people using the service were put at risk of

acquiring an infection as the cleanliness of medical equipment was not being properly

maintained.

We saw that the antibacterial scrub to clean hands and kill bacteria that was in use by the

sink in the treatment room had expired in 2009, and could be ineffective. This meant that

people were being put at risk of acquiring a healthcare associated infection.

One of the treatment rooms did not have a clinical waste bin, which should be used to safely

dispose of materials that need to be incinerated after being in contact with open wounds

during treatment. We saw that there was an uncovered mesh bin on the floor. We asked the

practice manager about the mesh bin and they said, "It does have cotton wool in it that at

times has blood on it, as it is used after an injection". This meant that people were being put

at risk because of exposure to materials that may spread health care related infections.

We observed that the clinic rooms were not clean or hygienic. We observed dust and

cobwebs in areas where treatment would be taking place. A member of staff told us, "We

have not had a cleaner for over a year now, I clean every week but it is difficult due to the

amount of work I have to do". This meant that the clinical areas were not being maintained to

an appropriate standard of cleanliness and hygiene.

Our judgement

People were being put at risk of infection because equipment was being used past its expiry

date. Clinical areas were not cleaned to a sufficient level of cleanliness and hygiene.

13

Outcome 9: Management of medicines

Minor

We found that there were packets of returned dispensed medicines in the GP’s consulting

room. We discussed this with the practice manager and the GP. They were not clear how to

deal with such medicines, and they had no procedure in place to address this.

Our judgement

People were not protected against the risks associated with the unsafe use and

management of medicines because the provider did not have arrangements for disposing of

returned medicines.

Moderate

The surgery’s medicines policy stated that it only dispensed medicines in an emergency and

that no medical gases or controlled drugs were stored or dispensed. We saw that there was

a rectal preparation and three inhalers which were past their expiry dates. The doctor told us

that the medicines were for demonstration purposes only so that patients could better

understand how to either take or use their medicines.

He told us that he did not have in place any procedure for checking the expiry dates of

medicines and removing any that had passed these dates for appropriate disposal. We

found that medicines were not stored in any order. The provider confirmed that there was no

system to the way the medicines were stored. This meant that it was difficult to safely select

particular medicines.

Our judgement

Medicines were not kept or disposed of appropriately because the provider did not have

appropriate arrangements in place. This meant that people were not protected against the

risks associated with the unsafe use and management of medicines.

Major

We saw three emergency anaphylactic shock kits available at the practice. We checked the

contents of all the kits and found that the medicine contents of the kit kept in the treatment

14

room had expired. This included adrenaline injection and hydrocortisone injection. We also

looked in a bag described by the doctor as his call out bag. The doctor told us that the bag

was no longer used as he no longer provided a call out service, but that he had not disposed

of the contents or removed the bag from the treatment room.

We checked the refrigerator where vaccines were kept. We looked at 17 vaccines for

influenza, yellow fever and tick-borne encephalitis. Fourteen of the vaccines were within their

expiry dates. All three of the tick-borne encephalitis vaccines were past their expiry dates.

We could find no evidence that the expiry date of the vaccines was routinely checked and

recorded, and the out-of-date vaccines were more than a month past their expiry dates. The

doctor and the clinic manager told us that the practice did not have a process to check expiry

dates of all medicines and vaccines and dispose of out-of-date items appropriately. This

meant that people were not protected from the risks associated with the unsafe management

of medicines.

Our judgement

People were not protected against the risks associated with the unsafe use and

management of medicines. This was because the provider did not have appropriate

arrangements in place in relation to the recording and the appropriate disposal of

medications.

15

Outcome 10: Safety and suitability of premises

Minor

At the time of our inspection, the fire door at the back of the clinic had been wedged open.

We saw that two doors in the premises had combination locks fitted to them but were left

unlocked. These were doors to the medical supplies and the staff room. Both rooms were

unattended. The medical supplies room contained a wheelchair and spare couch.

We checked the practice’s security risk assessment and the security policy, which were both

up to date. However, both stated that fire doors must not be wedged open and should be

fully closed at all times. They also stated that rooms with combination locks must be kept

locked at all times when unattended. These were clear security risks that could have

compromised the safety and wellbeing of staff and people who used the service.

We raised these issues with the practice manager, who acknowledged they often left the fire

door open in contravention of the policy. The practice manager said they would address both

matters with staff.

Our judgement

People were not protected from the risks associated with unsafe premises. This was

because the provider had not taken appropriate measures in relation to the security of the

premises and fire doors operating properly.

Moderate

There was an open plan reception area and a small waiting room but this did not provide

sufficient seating for people waiting to be seen at busy times. This meant that people often

had to stand in the entrance hall, which resulted in the area becoming crowded. The carpets

throughout the entrance hall were ripped in three places where people were standing. The

crowded area, as well as the condition of the carpets, posed a trip hazard. It also meant the

waiting area could not be directly observed to recognise a deteriorating patient.

We spoke with three patients at the time of our inspection. All three said that although they

thought the care and treatment provided by the staff was good, they found that at certain

times the premises were overcrowded and it was easy to trip or stumble when moving

through the waiting area. We spoke with the practice manager who recognised that this was

16

a problem. Although the practice did not own the premises, they had not taken steps to

assess and mitigate this risk.

Our judgement

The provider has not taken steps to provide care in suitably designed premises, particularly

the design and layout of the reception and waiting areas. This meant that people were not

protected against the risk of unsuitable premises.

Major

When we entered the building we found that there was a smell of damp. We saw that in the

treatment rooms on the ground floor, including the room used for minor surgery, the lower

sections of the walls had rising damp, which had caused wallpaper to peel away from the

walls. Paint was peeling from the skirting boards. When we looked at the staff kitchen, we

found a rodent trap on the floor behind a waste bin and what appeared to be mouse

droppings on the floor. We immediately raised our concerns with the practice manager, who

said they had informed the local environmental health department about rodent infestation

but they were finding it difficult to eradicate this.

In the reception area there was an electrical junction above the desk that had not been

boxed in. This meant that live wires were exposed. When we raised this matter with the

practice manager and asked to see the current electrical safety certificate, they could not

find it. Staff could not recall when an electrician had last visited the practice. There was no

current fire risk assessment or fire safety certificate available. This was a serious risk to

patients, staff, and other visitors.

We spoke to the practice manager who confirmed that they owned the building. The

manager said they were aware of these problems but they did not have plans to address

them.

Our judgement

People were not protected against the risks associated with unsafe or unsuitable premises.

The provider had not adequately maintained the premises.

17

Outcome 11: Safety, availability and suitability of equipment

Minor

The practice had four consulting rooms that were in constant use, each with its own blood

pressure machine. We looked at the records for maintenance checks of these machines.

The latest check was two weeks before our visit, which showed a requirement to order new

adult cuffs for two of the four blood pressure machines. These were to replace two that were

found to be serviceable, but showing signs of wear. The practice manager acknowledged

that the cuffs would become unserviceable in the near future and therefore the machines

might not record accurate results. This could lead to a misdiagnosis, putting people at risk.

The practice manager told us they did not have a system to review maintenance reports,

relying instead on staff to raise concerns, and they were unaware of this issue. They had not

ordered the replacement cuffs. We spoke to a practice nurse who told us that while they

were confident the cuffs were still fit for purpose, they would not be so in the near future.

This meant that people were not protected from the risk of using unsafe equipment because

the provider did not have suitable arrangements in place to properly maintain equipment.

The practice manager told us that the cuffs would be ordered immediately.

Our judgement

Although equipment was available, the practice had failed to make suitable arrangements to

protect people from unsafe equipment.

Moderate

The provider could not show evidence that all instruments and equipment used in the

practice were properly maintained and calibrated in accordance with the manufacturer’s

guidance.

The practice manager told us that one specialist piece of equipment used by the practice

nurse was regularly serviced and that a second instrument used to cauterise wounds after

minor surgery was subject to guarantee. The practice manager told us that no other

instruments or equipment, including scales and digital blood pressure monitors, were subject

to regular maintenance or calibration.

We asked clinical staff how they could be sure that instruments were working properly. One

member of clinical staff told us that they checked some instruments, such as scales,

18

themselves. Another told us that they had assumed that all the instruments were regularly

checked and a third member of staff told us that they could not be sure that some

instruments were working correctly. We found a number of disposable instruments that had

passed their expiry date. We spoke with one member of clinical staff who did not recognise

that the instruments we picked out had expired and should not be used. We removed the

instruments that had passed their expiry date from two treatment rooms and bought them to

the attention of the practice manager. The provider could not be sure that all instruments in

the practice were safe to use as some had passed their expiry dates because they did not

make regular checks.

We asked the practice manager whether a Portable Appliance Testing (PAT) certificate was

available for non-medical equipment in use in the practice (for example for computers). They

told us there were no current PAT certificates.

Our judgement

The provider had not made suitable arrangements to protect people from the risks of unsafe

equipment.

Major

We saw staff providing a wheelchair to help people who were unable to walk from their cars

into the building. The wheelchair had no footplates and had two flat tyres, which meant that

people using it were at risk of leg and back injury. During our inspection, we saw a person

using the wheelchair whose left leg became lodged underneath it as there were no

footplates to rest their foot on. We spoke to the manager and staff about this. They were not

able to locate the footplates and were not aware of the flat tyres. The manager told us, “It

was donated to the surgery, but we can’t afford to get it maintained or insured, so we just tell

people they can use it, but at their own risk.”

We looked at the defibrillator machine at the surgery. The machine had an ‘out of order’

notice on it, and the pads were past their use by date. When we asked to see this machine

working, the batteries were not charged and the machine would not switch on. The staff

were not able to show us a protocol for maintaining this equipment and the manager told us

the senior partner usually dealt with this. However the senior partner was on leave at the

time of our inspection and the other partners were unable to provide any information.

Our judgement

19

Patients were not protected from the risks of unsafe equipment. This is because equipment

was not properly maintained or suitable for its purpose.

20

Outcome 12: Requirements relating to workers

Minor

The nurse manager told us that she checked the registration of nursing staff with the Nursing

and Midwifery Council. Nursing staff were asked to inform the practice when their

registration was renewed. The nurse manager did not record this information and therefore

the provider did not know if all registrations were currently valid.

Our judgement

The provider could not be certain that people were cared for by suitably registered staff

because they did not ensure that staff were registered with relevant professional bodies

where this was legally required in relation to the work that person was to perform.

Moderate

We found that the provider had retained no evidence to show that they had carried out the

required pre-employment checks for two locum GPs working at the practice. The practice

had carried out a risk assessment for all roles within the practice and as a result, their policy

said that all new clinical staff were required to have a Disclosure and Barring Service (DBS)

check.

When recruiting the locum GPs, the practice had not followed this policy as they had not

checked that the locums were on the Performers List. As such, we found that the provider

could not be assured, and had no evidence to demonstrate, that these medical professionals

were registered with their professional body, and that they had a DBS disclosure, indemnity

insurance or proof of qualifications.

Our judgement

Patients were not protected because the provider had not carried out an effective

recruitment process.

Major

We reviewed a sample of four records for staff who had been recruited in the last year. We

found that the practice had not required two nurses to apply for DBS checks – one who had

been working for two months and one for seven months. We asked the practice manager

21

when they required new staff to obtain a DBS check. It was clear that they had not

considered which staff needed a DBS check, and which type of check that would be.

They had not made any risk assessments of the roles of staff at the practice and there was

no policy in place to ensure that appropriate checks were made for new staff. This meant

that the safety and welfare of people using the service was compromised, because the

provider had not followed safe recruitment practices.

Our judgement

People were not protected because the provider did not operate an effective recruitment

process or make risk assessments in respect of staff roles.

22

Outcome 13: Staffing

Minor

The practice manager told us that there had been a GP vacancy for some time, which had

resulted in scheduled home visits occasionally being cancelled or rearranged because of the

shortage of staff. We saw evidence that urgent home visits were not affected and that the

practice manager prioritised these. However, this meant that people who required non-

urgent home visits did not receive the care and treatment they needed promptly.

We saw the practice was following a recruitment process to fill the vacancy and that

interviews with two GPs were scheduled for the coming week. However, despite deciding

that a doctor was needed, the practice had taken three months to advertise the vacancy and

had not arranged appropriate extra sessions by locums or existing doctors. It would still take

up to a month to fill the vacancy.

Our judgement

There were not enough qualified, skilled and experienced staff to safeguard people’s health,

safety and welfare.

Moderate

One person told us that they had been asked to rearrange an appointment at their last visit.

When we spoke with one of the GPs at the practice, they told us that every Wednesday no

nurses were available to assist during the afternoon surgery because they were asked to

help with other work. This was in contravention of their own staffing schedule, which we

were shown, and which the practice manager told us was for the minimum staffing required

to meet people’s needs.

This meant that sometimes they had to rearrange patients’ appointments. We checked the

rotas and saw that the number of staff on duty during the afternoon was fixed, and never

varied to reflect an additional mother and baby clinic, which took up the nurses’ time on a

Wednesday afternoon.

Our judgement

The provider did not have enough suitably qualified, skilled and experienced staff to meet

the needs of people at all times.

23

Major

This walk-in centre did not have enough staff to deal promptly with the number of people

attending for treatment, particularly at weekends. Two patients told us that they had been

waiting a long time to be seen, and were considering leaving. When we spoke to the practice

manager they told us that, as a result of pressure on staffing, two of the four nurse

practitioners had recently left. This caused even more pressure on remaining staff.

The number of patients using the centre had recently risen because of the closure of a bus

route to the walk-in centre five miles away. One nurse told us that in some cases, patients

had left the clinic because they had waited too long. Also, the practice manager told us that

the number of reported safety incidents had risen recently. They had discussed this at the

last staff meeting and had attributed it to the pressure they are under at weekends. They had

no plans to recruit suitable replacement staff.

Our judgement

The provider had not ensured that there were enough qualified, skilled and experienced staff

to meet people’s needs.

24

Outcome 14: Supporting staff

Minor

We looked at the appraisal and supervision records for reception staff. Although these were

all in place, we saw there was no consistency in the frequency of appraisals or supervision.

We saw that the practice’s appraisals policy stated that these should be held annually.

However, from the records we saw, some staff had not received an appraisal for two years.

The practice was not following its own policy. This meant that the practice could not be sure

that staff were supported to deliver care and treatment safely and to an appropriate

standard.

Our judgement

People were cared for by staff who had insufficient support to ensure that they delivered

care to an appropriate standard.

Moderate

Some staff had not received recent training in a number of key areas and no training was

planned. Some members of staff reported that they had not received training in basic life

support. There was no record of any training in basic life support for any staff. In addition,

some staff said they had not received training in safeguarding vulnerable people. There were

inconsistencies in the understanding of some staff about these aspects of care. There was a

risk of people receiving poor care, which could have a significant impact on their health,

safety and welfare.

Our judgement

There was a lack of training for staff in some key areas, which may result in people’s needs

not being fully met. This was because the provider did not have suitable arrangements to

ensure that staff received appropriate training to deliver care and treatment safely and to an

appropriate standard.

Major

This practice was run by a single-handed GP who had employed a salaried GP to manage

the practice while they worked elsewhere. The salaried GP told us that they had frequently

25

requested refresher training sessions from the principal GP to ensure they were up to date

with current practice procedures and guidelines. They said this was particularly important as

they were working as the sole GP in the practice. However, we were told this had not

happened and the records we were shown identified that the salaried GP had not received

any professional or practice orientated development for the past two years since first working

in the practice.

A practice nurse who worked in the surgery also told us they had not received any training

updates despite making requests. The records we saw confirmed this.

We found no evidence of processes in place to ensure the regular appraisal or supervision

of staff, and both the practice nurse and the salaried GP reported that they did not feel

supported when working at the practice. The salaried GP told us that he felt professionally

isolated. This meant people’s safety and health needs were not being met by staff who were

appropriately well supported.

Our judgement

The provider did not have suitable arrangements in place to ensure staff received

appropriate support or professional development to provide care and treatment to people

safely and to an appropriate standard.

26

Outcome 16: Assessing and monitoring the quality of service provision

Minor

The practice manager told us that she occasionally asked for feedback from staff and people

using the service through questionnaires, which were available on the reception desk. They

said their policy was to collate these responses and produce an annual summary, as a

minimum necessary to reach an informed view about the care and treatment provided. We

saw that the most recent collation of views was produced 15 months previously. The practice

manager agreed that this was insufficiently regular to enable them to come to an informed

view about the standard of care and treatment provided.

Our judgement

The provider did not have a system in place to regularly assess and monitor the quality of

the services provided by gathering the views of staff and patients, which would enable the

provider to have an informed view of the standard of care and treatment provided.

Moderate

We examined patient surveys that the provider had undertaken six months previously.

However this information had yet to be analysed or used to assess service quality in a timely

manner.

We also reviewed audits of minor surgery carried out at the practice. We found that these

audits were detailed and sought to assess the quality and success of the procedures, but

many were not dated. The provider confirmed that no action had been taken where issues

were identified, although these had not identified a risk to patients’ safety. We also found the

provider had not completed infection control risk assessments for the treatment room and

consulting areas for seven months. The provider’s policy stated that these needed to be

carried out every six months. This meant that there was a risk of people receiving unsafe

care and treatment in these rooms.

Our judgement

The provider did not have a system in place to regularly identify, assess and manage the

quality of the services provided, to enable the provider to come to an informed view of the

standard of care and treatment provided.

27

Major

We asked the practice manager how the practice assessed and monitored the quality of its

services. There was no evidence of any recent monitoring carried out in the last 12 months.

When we asked the practice manager how they monitored the quality of their service in

areas such as medicines management or infection control, they told us they had not done

anything for some time.

We looked at the records which showed that no monitoring had been conducted since the

previous practice manager left two years previously. There was also no process in place to

consider, identify and reduce risks particular to the practice. This meant that the provider

was not protecting patients from the risk of inappropriate care or treatment because they

were not considering or monitoring the quality of services or identifying, assessing and

managing risks.

Our judgement

The provider did not have an effective system in place to regularly identify, assess and

manage risks to the health, welfare and safety of people who may be at risk from the

carrying on of the regulated activity.

28

Outcome 17: Complaints

Minor

We looked at the complaints log and saw that when people had made a complaint, this had

been responded to appropriately. However, people had sometimes not received a response

in a timely manner and within the timeframe stated in the practice’s own policy, which

reflected national guidelines.

Our judgement

There was a complaints system in place. However, people’s comments and complaints were

not always responded to appropriately because sometimes this was not done in a timely

manner.

Moderate

We spoke with the practice manager and one GP. They told us the practice had a

complaints policy in place and that all complaints were investigated. However, from the

records we looked at, we saw that not all issues raised were responded to appropriately. In

one case, we saw that the response from one GP to a patient’s complaint had not sufficiently

addressed the issues raised because it had asserted that a treatment decision had been

correct without giving reasons.

In other records we saw evidence that people’s complaints were not always listened to or

addressed appropriately. This meant that complaints were not managed effectively and

consistently to enable the practice to learn from issues raised.

Our judgement

Patients were not protected from unsafe or inappropriate care or treatment. This was

because there was no effective complaints system in place for responding appropriately to

complaints.

Major

The practice kept a record of all complaints, which we looked at during our inspection. We

saw that at least half of those recorded related to people complaining about the poor quality

of examination or failed diagnosis by one GP.

29

Specifically, we saw that two complaints related to someone who was given advice by a GP

to follow self-care, which records showed had been ineffective and a subsequent different

diagnosis was more appropriate. We saw that a high number of complaints were made

about the clinical treatment of this GP. We asked the practice manager and lead GP about

this; they told us the GP concerned was often perceived as abrupt due to a language barrier.

We asked how the practice was addressing this but were told that no processes were in

place to manage the issue. We also did not see any evidence of learning from complaints

being shared among staff.

Our judgement

Patients were not protected from unsafe or inappropriate care or treatment because the

provider did not have an effective complaints system in place. They did not make sure that

all complaints were fully investigated and, where practicable, resolved to the satisfaction of

the patients.

30

Outcome 21: Records

Minor

We saw that when the practice received blood result records from the hospital they filed

them appropriately in patient records, but on a monthly basis. In the meantime the results

were left in an unsecured filing tray behind the reception area. Reception staff told us that

clinical staff knew that they could sort through the blood results held at reception to find the

most up-to-date record. They advised us that the clinical staff should be able to determine

from the patient record whether there is an outstanding blood test result either waiting to be

filed or waiting to be returned from the hospital laboratory. This meant that the provider did

not hold an accurate record that included all appropriate and up-to-date information about a

patient’s conditions. Part of the patient record was not being held securely.

Our judgement

Patients were not always protected from the risks of unsafe or inappropriate care and

treatment because accurate records were not consistently maintained and records were not

held securely.

Moderate

During our inspection we witnessed a telephone conversation between a member of

reception staff and a patient. The receptionist was confirming to the patient that a copy of

their medical records had been posted to them the previous day by first class post, and so

should arrive imminently. After the call had ended, we asked the member of staff what

records had been sent by post. We were told this had included the person’s full medical

records held at the practice.

We were also told that these types of comprehensive medical records were routinely sent by

first class post. We discussed this with the staff on duty and asked about their understanding

of managing records securely. We found that reception staff were not aware of potential

problems when sending a full and comprehensive copy of medical records by regular posting

methods and the risk to the security of records. The issue was discussed with the practice

manager who confirmed that there was not a protocol or policy in place about how to make

sure records were transported securely.

Our judgement

31

Patients’ personal records were not kept securely at all times.

Major

At the practice, patients’ medical records were stored either on a computer system or within

a locked cabinet away from the main waiting room. While observing the main reception area,

we saw the single member of staff covering reception leave their computer unattended and

unlocked. We saw confidential information was visibly on display. The position of the

computer meant that people sitting in the reception area could see the screen.

While the reception was unstaffed we also saw a GP walk by and place a patient’s record on

the reception desk where it could be seen by patients waiting to be booked in. We spoke to

the receptionist and the GP about how they manage the confidentiality of information and

told them what we had seen. They had not considered that this meant that confidential

records were not managed securely at all times.

Our judgement

Systems were not in place to ensure that patients’ confidential records were kept securely at

all times.

32