All inspections: The Village Surgery - Care Quality Commission

The Village Surgery is an NHS GP practice with one site located in Alfreton, Derbyshire and a branch site at Pinxton.

The practice was last rated Requires improvement (published 22 November 2022). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF).

We carried out an announced on-site assessment on 18 July 2024 to follow up on breaches identified at the last inspection. The assessment included a remote activity which included interviews with staff and clinical searches on the practice’s patient records system. Prior to the assessment we requested evidence from the practice. We assessed 33 quality statements across safe, effective, responsive and well led key questions.

We assessed some but not all quality statements at this visit which means we use the ratings from the previous inspection to rate the key question of caring and a proportion of the effective key question. This assessment did not cover all parts of our SAF; therefore, we have only updated scores and ratings for those areas which we have assessed. We will carry out future assessments to cover other parts of the Framework and will update our website with our findings.

At this assessment we found the provider had made significant improvements. The practice now had safe recruitment systems in place and effective systems to help protect people from abuse and neglect. People’s care and treatment was now usually delivered in line with current guidance and evidence, and by staff who had the required skills, knowledge and experience. There were now clear and effective governance structures in place and comprehensive quality assurance systems.

We carried out an announced comprehensive inspection at The Village Surgery on 25 and 27 October 2022. Overall, the practice is rated as requires improvement. We rated the key questions safe, responsive and well-led as requires improvement and effective and caring as good.

Following our previous inspections on 4 April 2022 and 13 December 2021, the practice was rated inadequate overall and placed into special measures. At our inspection on 4 April 2022 we rated the key questions for safe and well-led as inadequate, effective as requires improvement and caring and responsive as good.

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

Why we carried out this inspection

We carried out a comprehensive inspection because the practice was in special measures and to follow up on breaches of regulation from our previous inspection.

We inspected the key questions safe, effective, caring, responsive and well-led.
Breaches of regulations relating to safe care and treatment and good governance.
Shoulds identified in the previous inspection.
Ratings carried forward from the previous inspection.

How we carried out the inspection

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

This included:

Conducting staff interviews using video conferencing.
Completing clinical searches on the practice’s patient records system (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 site visit.
Staff questionnaires

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 the practice as requires improvement overall.

We rated the practice as requires improvement for providing safe care and treatment because there had been significant improvements. In particular:

Monitoring to ensure professional registrations were in date was in place.
Systems to verify PCN staff working within the practice were appropriately recruited and supported were in place.
Recruitment files were organised.
There was a system in place for monitoring staff immunisation and, risk assessments had been completed for non-clinical staff where required.
Action plans had been put in place to mitigate issues identified in risk assessments, for example fire prevention.
Test results were reviewed in a timely manner.
Systems to monitor the prescribing and consultations of non-medical prescribers had been implemented.
Patients on high risk medicines were monitored appropriately.
Themes and trends related to significant events had been identified although this was not formally documented.

However, we found ongoing issues:

A clinical member of staff had not completed training in safeguarding children and infection prevention.
Recruitment checks were not fully carried out in accordance with regulations for some staff.
A risk assessment was not in place for a clinical member of staff whose immunity status to hepatis B was unknown.
Medicines and Healthcare products Regulatory Agency (MHRA) and Central Alerting System (CAS) alerts were not always followed.
Some Patient Specific Directions (PSD) were not always authorised by a prescriber before a medicine was administered.
Systems to manage the prescribing of a high number of short acting asthma inhalers were not effective.

We rated the practice as good for providing an effective service because:

There had been significant improvements in the monitoring of patients with potential diabetes or chronic kidney disease (CKD).
Patients with diabetes, CKD or hypothyroidism had either received the appropriate monitoring or been invited to receive the appropriate monitoring.
Systems to address poor staff performance had been put in place.
Whilst cervical screening rates remained slightly below the national target, the provider was able to describe the action they had taken to try and address it.

We rated the practice as good for providing a caring service because:

Staff treated patients with kindness, respect and compassion.
There were systems in place to support carers.

We rated the practice as requires improvement for providing a responsive service because:

Ward rounds for patients living in care homes had been provided by a GP at a time that was convenient to the homes.
Response letters to patients’ complaints had been updated to inform patients of their right to complain to the Parliamentary and Health Service Ombudsman if they were unsatisfied with the practice’s response to their complaint.
In response to patient feedback, the practice had recruited more staff to support access to appointments and changed their appointment booking system.

However:

The National GP Patient Survey results in relation to access to appointments had deteriorated, specifically in relation to patient experience of making an appointment, and satisfaction with appointments offered.

We rated the practice as requires improvement for providing a well-led service because there had been significant improvements. In particular:

There were systems in place to review the accuracy of policies and compliance with them.
Risk assessments had been completed and action plans put in place to mitigate potential risks.
Systems for managing poor staff performance had been put in place.
Staff were aware of the practice’s vision.

However:

Governance structures and systems were not fully embedded into practice. In particular systems for:

Ensuring recruitment checks were in line with regulations.
Managing Medicines and Healthcare products Regulatory Agency (MHRA) and Central Alerting System (CAS) alerts.
Ensuring Patient Specific Directions were authorised prior to administration of a medicine.
Managing the repeat prescribing of short acting asthma inhalers.
Ensuring a risk assessment was completed for a clinical member of staff whose immunity status to hepatis B was unknown.

We found two breaches of regulations. The provider must:

Ensure specified information is available regarding each person employed and where appropriate, persons employed are registered with the relevant professional body.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

Continue to review and identify ways to improve the uptake of cervical screening.
Support all clinical staff to complete mandatory training.
Embed into practice the new system for tracking prescription stationery throughout the practice.
Monitor the impact of the changes made to improve patient access to appointments and respond accordingly.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

We carried out an announced comprehensive inspection at The Village Surgery. We carried out our remote searches on 31 March 2022 and an onsite visit on 4 April 2022. Overall, the practice is rated as inadequate. We rated the key questions:

Safe: Inadequate

Effective: Requires improvement

Caring: Good

Responsive Good

Well-led: Inadequate

Following our previous inspection on 13 December 2021, the practice was rated Inadequate overall and placed into special measures:

Safe: Inadequate

Effective: Requires improvement

Caring: Good

Responsive: Requires improvement

Well-led: Inadequate

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

Why we carried out this inspection.

This inspection was a comprehensive inspection to follow up on:

The key questions safe, effective, caring, responsive and well-led
Breaches of regulations relating to safe care and treatment and good governance.
Shoulds identified in the previous inspection
Ratings carried forward from the previous inspection

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 rated the practice as inadequate for providing safe care and treatment because:

There had been improvements in many of the issues we identified at our previous inspection in December 2021. In particular, the prescribing of high-risk medicines, acting on Medicines and Healthcare products Regulatory Agency (MHRA) alerts reviewed at our previous inspection, storage of prescription stationery and infection control.
The practice was in the process of recruiting additional salaried GPs, with locum GPs in place in the interim. Additional practice nurse hours had already recruited to.

However, we found ongoing issues:

Recruitment checks were not fully carried out in accordance with regulations and systems to monitor that staff vaccination was maintained in line with national guidance were disorganised and lacked clarity.
It was unclear if the recommendations in the legionella and fire risk assessments and buildings surveys had been actioned.
Test results were not always reviewed in a timely manner.
Audits to monitor the prescribing competence of all non-medical prescribers were in place. However, non-clinical prescribers had not been provided with feedback or clinical supervision.
Most patients on high-risk medicines were monitored appropriately. Where they had not been, we found that systems were in place to address this.
One MHRA alert we reviewed had not been fully actioned.
Themes and trends relating to significant events were not identified to aid improvement.

We rated the practice as requires improvement for providing an effective service because:

There had been improvements in some of the issues we identified at our previous inspection, in particular:

Asthma and medication reviews had been completed when it was appropriate to do so. This included patients who had been prescribed two or more courses of rescue steroid treatment for their asthma.
All staff, except salaried GPs, had received an appraisal.
Patients with long-term conditions had been contacted for a review of their condition and medication.
An additional practice nurse had been recruited, increasing the number of cervical screening appointments available to patients.

However,

We continued to identify potential patients with a missed diagnosis of diabetes or chronic kidney disease (CKD).
Patients with diabetes, CKD or hypothyroidism had not always received the required monitoring.
Systems to address poor staff performance were not effective

We rated the practice as good for providing a caring service because:

Staff treated patients with kindness, respect and compassion.
There were systems in place to support carers

We rated the practice as good for providing a responsive service because:

There had been improvements in the recording and investigating of complaints. However, patients were not informed of their right to take their complaint to the Parliamentary and Health Service Ombudsman if they were unsatisfied with the practice’s response.
The practice organised and delivered services to meet patients’ needs. They provided weekly ward rounds to local care homes however, one representative of a care home told us they had been as late as 10pm.

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

There had been improvements in some of the issues we identified at our previous inspection, in particular:

Some staff felt the GP partners had tried to be more visible within the practice.
An audit had been completed by the provider to assess and act on the potential risk of missed patient referrals to secondary care.
There was some improvement in staff morale due to recent staff recruitment.
Policies had been updated.

However:

Systems to ensure accuracy and compliance to the policies were not always effective.
Governance structures and systems were being developed, however they were not fully embedded into practice.
Risk assessments had been completed however, it was not always clear if risks identified had been mitigated.
Staff felt that their concerns were not always acted upon for example, managing poor staff performance.

We found two 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, the provider should:

Develop an organised structure to monitor that staff immunisations were in line with national guidance.
Monitor cervical screening rates to ensure the increased number of practice nurse appointments was having an impact.
Provide ward rounds to patients living in care homes within reasonable time frames.
Inform patients of their right to take their complaint to the Parliamentary and Health Service Ombudsman if they were unsatisfied with the practice’s response, as detailed in the practice’s complaints policy.

This service was placed in special measures in January 2022. Insufficient improvements have been made such that there remains a rating of inadequate for The Village Surgery. Therefore we are taking 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 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.

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 Car

We carried out an announced inspection at The Village Surgery on 10 and 13 December 2021. Overall, the practice is rated as inadequate. It is rated as inadequate in safe and well-led, requires improvement in effective and responsive and good in caring.

The Village Surgery was previously inspected on 16 August 2016 and rated good overall and in all domains.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

Concerns shared with the Care Quality Commission.

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 rated the practice as inadequate for providing safe care and treatment. We took this action because:

The practice did not maintain a register of vulnerable adults. Alerts had not been added to some of the records of people living in the same household as a child with a safeguarding concern.
Recruitment checks were not carried out in accordance with regulations and risk assessments were not in place to mitigate potential risks.
There was no system in place to monitor that staff vaccination was maintained in line with national guidance.
It was unclear if the recommendations in the legionella risk assessment and facet surveys had been actioned.
Staff told us there were not enough staff to provide appointments and that clinical staff were working excessive hours.
There was a trend in delays of patient referrals to secondary care including referrals for potential cancer. We instructed the provider to put in place an action plan to identify any potential referrals that may have been missed.
Test results were not always reviewed in a timely manner.
Prescription stationery was not stored securely when the practice was closed.
Systems to monitor the prescribing competence of all non-medical prescribers were not in place.
Processes for the safe handling of requests for repeat medicines and the monitoring of patients prescribed high risk medicines were not effective.
Systems to investigate the unusual prescribing of controlled drugs had not been followed.
Opportunities to raise and investigate significant events had been missed and there was a lack of detail in the analysis of significant events.
The provider could not always demonstrate that Medicines and Healthcare products Regulatory Agency (MHRA) alerts were incorporated into clinical practice.

However, we noted that:

There were some systems in place to keep people safeguarded from abuse.
Appropriate standards of cleanliness and hygiene were met.

We rated the practice as requires improvement for effective. We took this action because:

There were potential patients with a missed diagnoses of diabetes or chronic kidney disease (CKD).
Asthma reviews or medication reviews had not always been completed when it was appropriate to do so.
Patients with diabetes, CKD or hypothyroidism had not always received the required monitoring.
Some staff had not received an appraisal.

However, we noted that:

Staff worked together and with other organisations to deliver effective care and treatment.
Staff were proactive in helping patients to live healthier lives.

We rated the practice as good for caring. We took this action because:

Staff treated patients with kindness, respect and compassion.
There were systems in place to support carers.

We rated the practice as requires improvement for providing a responsive service. We took this action because:

Opportunities to raise and investigate complaints had been missed.
Complaints were not always handled in line with the practice’s complaints policy.

However, we noted that:

The practice organised and delivered services to meet patients’ needs.

We rated the practice as inadequate in well-led. We took this action because:

Staff we spoke with told us that the provider was not visible and they did not listen or act on staff concerns.
Systems for managing poor staff performance were not effective.
Systems were not in place to support staff wellbeing.
Policies and procedures were not always followed.
Effective governance structures and systems were not in place.
Risk assessments to mitigate potential risks to patients and staff had not always been completed where required.
Action had not been taken to assess and act on the potential risk and impact of possibly missed patient referrals to secondary care.
Statutory notifications had not been sent to the Care Quality Commission as required under The Care Quality Commission (Registration) Regulations 2009.

However, we noted that:

The practice had adapted its systems to ensure services continued to be delivered throughout the Covid-19 pandemic.
The practice had carried out clinical audits to make improvements within the service.

We found two 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, the provider should:

Update their infection prevention audit to include the action needed to address a broken pedal on one of the clinical waste bins, undated sharps bins and appropriate storage of mops.
Store prescription stationery securely when the practice is closed.
Carry out regular fire drills at the branch practice.

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.

We found serious concerns about patient safety. We told the practice to submit an action plan by 17 December 2021 to detail how the serious concerns that put patients at risk would be addressed. An action plan was submitted.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Village Surgery on 16 August 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

The practice demonstrated an open and transparent approach to safety. There were systems in place to enable staff to report and record significant events. Learning from significant events was shared with relevant staff.

Risks to patients were assessed and well managed. There were arrangements in place to review risks on an ongoing basis to ensure patients and staff were kept safe.
Staff delivered care and treatment in line with evidence based guidance and local guidelines. Training was provided for staff to ensure they had the skills and knowledge required to deliver effective care and treatment for patients.
Staff undertook health promotion events to encourage healthy living in a variety of innovative ways, for example taking to the streets dressed as a cigarette handing out smoking cessation advice.
Feedback from patients was that they were treated with kindness, in a friendly manner respected and were involved in decisions about their care.
Regular clinical audits were undertaken within the practice to drive improvement, shared within the group of three practices and future ones planned to maximise the effectiveness.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
Patients said they generally found it easy to make an urgent appointment and that staff would always accommodate them where possible.
The practice had good facilities and was well equipped to treat patients and meet their needs. Adjustments had been made to the premises to ensure these were suitable for patients with a disability.
There was a clear leadership structure which all staff were aware of. Staff told us they felt supported by the partners and management. The practice proactively sought feedback from staff and patients, which it acted on.
The provider was aware of and complied with the requirements of the duty of candour.

We saw areas of outstanding practice which included

The partners had highlighted the rate of teenage pregnancy at the practice was the highest in Derbyshire. School nurses were unable to give contraceptive advice, the nearest family planning clinic was in a local town three miles away and the surgery had no female medical staff.The practice had initiated a pilot to bring family planning consultants into the practice which had led to significant reductions in the rate of teenage pregnancy compared to others in the local area and continuing increase in contraceptive prescribing to under 18s.

The practice adopted improvement to ensure uptake of screening for patients with a learning disability was increased which had been recognised nationally

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

The Village Surgery

All Inspections

During an assessment under our new approach

27 October 2022

During a routine inspection

4 April 2022

During a routine inspection

10 and 13 December 2021

During a routine inspection

16 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)