The Care Quality Commission
  • Doctor
  • GP practice

Archived: Seaforth Village Surgery

Overall: Good read more about inspection ratings

20 Seaforth Road, Litherland, Liverpool, Merseyside, L21 4LF

Provided and run by:
SSP Health Ltd

All Inspections

8 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an inspection at Seaforth Village Surgery in November 2014 and found breaches of regulations relating to the safe and effective delivery of patient services. The overall rating of the practice in November 2014 was inadequate and the practice was placed into special measures for six months. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance.

We carried out a further announced comprehensive inspection at the practice on 8 September 2015. This inspection was carried out to consider whether sufficient improvements had been made and to identify if the provider was now meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. At the inspection in September 2015, we found the practice had made significant improvements and they were now meeting all of the regulations which had previously been breached. The ratings for the practice have been updated to reflect our findings.

Specifically, we found the practice had improved systems in place for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for all the population groups it serves.

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

  • Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered in line with best practice guidance. Staff had received training appropriate for their roles and any further training needs had been identified and planned.
  • Patients spoke positively about the practice and its staff. They said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available, in different languages and easy to understand for the local population.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available on the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider should make improvements.

  • The practice had, as part of their contract an Enhanced Service, a target (2% of the practice population) to reduce unnecessary emergency admissions to secondary care. The provider should ensure that all personalised care plans relevant to this service are reviewed by the GP on a regular basis to prevent unnecessary hospital admissions.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

11/11/2014

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Seaforth Village Surgery. The practice is registered with the CQC to provide primary care services. We undertook a planned, comprehensive inspection on 11 November 2014 and we spoke with patients, relatives, staff and the practice management team.

The practice was rated as Inadequate.

Our key findings were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate fitness and recruitment checks on staff had not been undertaken. Staff had not attended child protection training.
  • Safety incidents were not reported, investigated or analysed by staff, this included complaints made by patients. Staff were not clear about the reporting of incidents, near misses and concerns and there was no evidence of learning and communication with staff.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example there was no evidence that local audits took place or that national audits resulted in improvements in patient care locally.
  • The practice was not always accessible and responsive to patients’ needs. There was a lack of awareness of the differing needs of the population and what support was available for the identified population groups.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity. However patients told us that the high use of locum GPs meant they did not receive continuity of care and this caused them some concern.
  • Urgent appointments were usually available on the day they were requested. However patients said that they were not always able to see the same GP at each visit.
  • The practice had no clear leadership structure, insufficient leadership capacity and a lack of formal governance and risk management arrangements.
  • Some staff reported a lack of confidence in raising concerns believing that effective actions would not be taken.

  • There were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve:

  • The provider must ensure that all staff are properly trained, supervised and supported at all times. Arrangements for staff must be improved to ensure staff are able to deliver care and treatment to patients safely and to an appropriate standard.
  • The provider must have an effective system in place to regularly assess and monitor the quality of services provided. They should have an effective system in place for identifying, assessing and managing risks related to the health and safety of service users and others. They must have an effective system in place for reporting, analysing, learning from and disseminating significant events and this must include all staff.
  • The provider must ensure its recruitment arrangements are in line with Regulation 21 and Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. This must include a Disclosure and Barring Service (DBS) check for all staff with chaperoning responsibilities.

Action the provider SHOULD take to improve:

  • Ensure doctors have available emergency drugs for use in patients’ homes or have in place a risk assessment to support their decision not to have these available.
  • Ensure there is a planned and preventative maintenance programme to ensure the environment is fit for purpose at all times.
  • The provider should review the use of locum GPs to ensure patients receive consistency and continuity of care when attending appointments.
  • The practice should review the systems and services in place to ensure the needs of patients identified in the population groups are met.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice