Dr Surendra Kumar Dhariwal NewApproachComprehensive Report ... ·...

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This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations. Ratings Overall rating for this service Inadequate ––– Are services safe? Inadequate ––– Are services effective? Inadequate ––– Are services caring? Requires improvement ––– Are services responsive to people’s needs? Requires improvement ––– Are services well-led? Inadequate ––– Dr Dr Sur Surendr endra Kumar umar Dhariw Dhariwal al Quality Report 688 Romford Road, Manor Park, London E12 5AJ Tel: 020 8478 0757 Website: No website Date of inspection visit: 29 June 2016 Date of publication: 03/11/2016 1 Dr Surendra Kumar Dhariwal Quality Report 03/11/2016

Transcript of Dr Surendra Kumar Dhariwal NewApproachComprehensive Report ... ·...

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This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Inadequate –––

Are services safe? Inadequate –––

Are services effective? Inadequate –––

Are services caring? Requires improvement –––

Are services responsive to people’s needs? Requires improvement –––

Are services well-led? Inadequate –––

DrDr SurSurendrendraa KKumarumar DhariwDhariwalalQuality Report

688 Romford Road,Manor Park,London E12 5AJTel: 020 8478 0757Website: No website

Date of inspection visit: 29 June 2016Date of publication: 03/11/2016

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Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 7

What people who use the service say 10

Areas for improvement 10

Detailed findings from this inspectionOur inspection team 11

Background to Dr Surendra Kumar Dhariwal 11

Why we carried out this inspection 11

How we carried out this inspection 11

Detailed findings 13

Overall summaryLetter from the Chief Inspector of GeneralPractice

We carried out an announced comprehensive inspectionat Dr Surendra Kumar Dhariwal on 29 June 2016. Overallthe practice is rated as inadequate.

Our key findings across all the areas we inspected were asfollows:

• Patients were at risk of harm because systems andprocesses were not in place to keep them safe. Forexample there was no health and safety or fire safetyrisk assessment and actions identified to addressconcerns with infection control practice had not beentaken.

• There was no emergency use oxygen or checks onequipment for dealing with a medical emergency andthere were multiple first aid items and medicines outof date.

• The practice was cluttered (including at a fire exit) andthere was no guidance for action in the event of a fire.

• Patients’ medical notes were in an unsecured publiclyaccessible area of the practice.

• The practice had not carried out safety testing ofelectrical equipment, some items had been calibratedand others such a set of baby scales had not.

• The premises carpet was visibly stained and somesurfaces dusty and clinical equipment was visibly dirty.

• The practice had a number of policies and proceduresto govern activity, but some were missing and othersoverdue a review, or had not been implemented suchas the recruitment policy, control of substanceshazardous to health (COSHH), and chaperoning andinduction procedures.

• Staff understood their responsibilities to raiseconcerns. However, reporting systems were ineffectiveand reviews and investigations were not thorough.Patients did not always receive an apology and therewas no evidence of learning and communication withstaff.

• Staff did not have access to current evidence basedguidance or safety alerts and had not been trained toprovide them with the skills, knowledge andexperience to deliver safe and effective care andtreatment.

Summary of findings

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• The practice had not sought to ensure complaintswere resolved from the complainant’s perspective orlearned lessons to make improvements followingconcerns and complaints.

• Patients were positive about their interactions withstaff and said they were treated with compassion anddignity.

• The practice had no clear leadership and managementstructure, insufficient leadership knowledge and skill,and limited formal governance arrangements.

The areas where the provider must make improvementsare:

• Ensure patients consent is appropriately sought andrecorded.

• Identify and mitigate risks to patient’s safety includingmedicines, equipment , infection control and in theevent of a medical emergency.

• Ensure premises and equipment are clean, safe and fitfor use.

• Implement effective systems and processes to assess,monitor and improve quality.

• Establish systems and processes to and identify andmitigate risks.

• Ensure appropriately staff are appropriately trainingand supported and implement all necessaryemployment checks for all staff.

The areas where the provider should makeimprovements are:

• Improve arrangements for patients unable tocommunicate their needs in English.

• Consider how to address a patient preference foraccess to a female GP.

• Make arrangements to ensure appropriate monitoringof prescription pads.

• Improve the process for complaints management.

I am placing this service in special measures. Servicesplaced in special measures will be inspected again withinsix months. If insufficient improvements have been madesuch that there remains a rating of inadequate for anypopulation group, key question or overall, we will takeaction in line with our enforcement procedures.

The service will be kept under review and if needed couldbe escalated to urgent enforcement action.

Special measures will give people who use the service thereassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings

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The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as inadequate for providing safe services andimprovements must be made.

• There were significant gaps in systems, processes and practicesin place to keep patients safe such as identification andmanagement of significant events and dissemination of safetyalerts to relevant staff.

• When things went wrong reviews and investigations did nottake place and lessons were not learned to improve safety inthe practice. Patients did not always receive a verbal andwritten apology.

• Patients were at risk of harm because systems and processeswere not in place, had weaknesses or were not implemented ina way to keep them safe. Areas of concern includedrecruitment, infection control and dealing with emergencies.

• Arrangements for managing medicines such as emergencymedicines and refrigerated medicines were not safe.

• The practice did not maintain appropriate standards ofpremises or equipment cleanliness and hygiene.

• Several processes were ineffective in keeping patients safe. Forexample there were gaps in staff training or no staff training inareas such as safeguarding, basic life support, infection control,fire safety and chaperoning.

• Several procedures for monitoring and managing risks topatients and staff were missing or had weaknesses such as nohealth and safety policy or risk assessment. There were noother risk assessments in place to monitor safety of thepremises such as legionella (Legionella is a term for a particularbacterium which can contaminate water systems in buildings).

• There were no systems to ensure results were received for allsamples sent for the cervical screening programme.

• Arrangements for fire safety, electrical safety testing andControl of Substances Hazardous to Health (COSHH) wereabsent or ineffective.

Inadequate –––

Are services effective?The practice is rated as inadequate for providing effective servicesand improvements must be made.

• There was minimal engagement with other providers of healthand social care.

Inadequate –––

Summary of findings

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• There was no evidence of an appraisal process for five years orsupport for any additional staff training that may be required.

• There was no two cycle auditing to drive quality improvementin patient outcomes.

• Data from the Quality and Outcomes Framework (QOF) showedpatient outcomes were comparable to local and nationalaverages.

• Care and treatment requirements such as patient’s informedconsent were not met.

• The practice could not demonstrate it assessed needs anddelivered care in line with relevant and current evidence basedguidance and standards.

Are services caring?The practice is rated as requires improvement for providing caringservices.

• Data from the national GP patient survey showed patients ratedthe practice as comparable to others for aspects of care.

• Patients said they were treated with compassion, dignity andrespect and they were involved in decisions about their careand treatment.

• Information for patients about the services available was notalways easy to understand or accessible. For example forpatients with difficulties communicating in English.

• We saw staff treated patients with kindness and respect, andmaintained patient and information confidentiality.

Requires improvement –––

Are services responsive to people’s needs?The practice is rated as requires improvement for providingresponsive services.

• The practice entrance doorway was not clearly signposted andnot suitable for people with visual, mobility or cognitiveimpairment.

• Information about how to complain was available but thepractice had not sought to ensure the complaint was resolvedfrom the complainant’s perspective and we found no evidencelessons were learnt from individual concerns and complaints.

• Practice staff reviewed the needs of its local population andengaged with the NHS England Area Team and ClinicalCommissioning Group to secure improvements to serviceswhere these were identified. For example, it had identified ithad a relatively high population of patients with diabetes andoffered enhanced diabetes care for these patients.

Requires improvement –––

Summary of findings

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• Patients said they found it easy to make an appointment with anamed GP and there was continuity of care, with urgentappointments available the same day.

• The practice had some facilities to meet patients’ needs.• Data from the national GP patient survey showed that patient’s

satisfaction with how they could access care and treatment wascomparable to or higher than local and national averages.

Are services well-led?The practice is rated as inadequate for being well-led.

• The practice did not have a clear vision and strategy. Staff werenot clear about their responsibilities in relation to the vision orstrategy.

• There was no clear leadership structure but staff felt supportedby management.

• The practice had a number of policies and procedures togovern activity, but these had not been reviewed since 2012and the recruitment and induction procedures were not fit forpurpose.

• The practice did not hold regular governance meetings andissues were discussed at ad hoc meetings.

• The practice had met with the patient participation group (PPG)but there were no improvement proposals or no evidence of aquality improvement process.

• Staff told us they felt supported. However, there was noevidence the practice provided staff with fundamental trainingsuch as basic life support, safeguarding or fire safety.

• There was no team or individual staff objective setting,performance reviews, or practice mission statement.

Inadequate –––

Summary of findings

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The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• The practice offered home visits and urgent appointments forthose with enhanced needs. However, there was no system inplace to follow up frail elderly patients following theirattendance at accident and emergency or unplannedadmission to hospital.

• The percentage of patients with rheumatoid arthritis, on theregister, who had had a face-to-face annual review in thepreceding 12 months was 100% compared to 91% within theCCG and 91% nationally.

• The practice identified 67 patients over the age of 75 that wereat risk of unplanned admission into hospital. Ninety six per cent(64 patients) had a care plan agreed or reviewed within the last12 months.

• Staff knew how to recognise signs of abuse in vulnerable adultsbut had not been trained at the practice, with the exception ofthe lead GP.

Inadequate –––

People with long term conditionsThe provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• These patients had a named GP and a structured annual reviewto check their health and medicines needs were being met.However, we found no evidence the named GP worked withrelevant health and care professionals to deliver amultidisciplinary package of care for patients with the mostcomplex needs.

• Performance for diabetes related indicators was 98% comparedto the CCG average of 87% and national average of 89%.

• The percentage of patients with hypertension having regularblood pressure tests was 91% compared to the CCG andnational averages of 84%.

• We checked three care plans for patients with diabetes thatwere satisfactory.

Inadequate –––

Summary of findings

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Families, children and young peopleThe provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• Appointments were available outside of school hours. However,the premises were not suitable for families, children and youngpeople. For example, cleaning chemicals such as bleach werenot safely stored and sharps and medicines were stored inopen trays at child height level.

• There were no systems in place to identify and follow upchildren who were at risk on the child protection register.

• 91% of patients diagnosed with asthma, on the register had anasthma review in the last 12 months compared to 78% withinthe CCG and 75% nationally.

• Childhood immunisation rates for the vaccines given werecomparable to CCG averages. For example, childhoodimmunisation rates for the vaccines given to under two yearolds ranged from 75% to 88% and five year olds from 81% to100%, (CCG ranged from 82% to 95%).

Inadequate –––

Working age people (including those recently retired andstudents)The provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• The age profile of patients at the practice is mainly those ofworking age, students and the recently retired but the servicesavailable did not fully reflect the needs of this group.

• Although the practice offered extended opening hours forappointments on Tuesday and Friday, appointments could onlybe booked by telephone and the practice had no website.

• The practice offered health promotion and screening thatreflects the needs for this age group.

Inadequate –––

People whose circumstances may make them vulnerableThe provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• We found no evidence the practice had worked withmulti-disciplinary teams in the case management of vulnerablepeople

Inadequate –––

Summary of findings

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• Staff knew how to recognise signs of abuse in vulnerable adultsand children but had not been trained at the practice, with theexception of the lead GP.

• The practice held a register of patients with a learning disabilityand offered these patients longer appointments.

• Staff were aware of their responsibilities regarding informationsharing, documentation of safeguarding concerns and how tocontact relevant agencies.

People experiencing poor mental health (including peoplewith dementia)The provider was rated as inadequate for safety, effectiveness andfor well-led and requires improvement for caring and responsive.The issues identified affected all patients including this populationgroup.

• There was no evidence the practice regularly worked withmulti-disciplinary teams in the case management of patientsexperiencing poor mental health, including those withdementia.

• The practice had no system in place to follow up for peoplewith mental health problems following their attendance ataccident and emergency or unplanned admission to hospital.

• Locally held data at the practice showed 42 patients currentlyhad a diagnosis of dementia, and 76% (31 patients) had a careplan review in place.

• Performance for mental health related indicators was 86%,which was comparable to the CCG average at 87% and thenational average of 93%.

• The practice had identified 34 patients on its register with amental health condition, 88% had an agreed care plan.

Inadequate –––

Summary of findings

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What people who use the service sayThe national GP patient survey results were published inJanuary 2016. The results showed the practice wasperforming in line with or better than local and nationalaverages. Three hundred and seventy seven forms weredistributed and 86 were returned. This represented six percent of the practice’s patient list.

• 95% found it easy to get through to this surgery byphone (CCG average 61%, national average of 73%).

• 88% were able to get an appointment to see or speakto someone the last time they tried (CCG average 66%,national average 76%).

• 81% described the overall experience of their GPsurgery as fairly good or very good which (CCG averageof 76%, national average of 85%).

• 73% said they would recommend their GP surgery tosomeone who has just moved to the local area (CCGaverage 69%, national average 79%).

As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection.We received 48 comment cards 44 of which were entirelypositive about the standard of care received with patientssaying staff listened and were polite and friendly. Threecards had mixed feedback and one was negative: threepatients expressed either long waiting times or needingmultiple appointments being an issue, and oneexpressed the reception staff had not always been polite.

We spoke with three patients during the inspection. Allthree patients said they were satisfied with the care theyreceived and thought staff were approachable,committed and caring.

The practice provided patient survey results it hadcollated in March 2016. Results indicated there was nonegative feedback; all 35 patients said they were happyand confident with GP care.

Areas for improvementAction the service MUST take to improve

• Ensure patients consent is appropriately sought andrecorded.

• Identify and mitigate risks to patient’s safety includingmedicines, equipment , infection control and in theevent of a medical emergency.

• Ensure premises and equipment are clean, safe and fitfor use.

• Implement effective systems and processes to assess,monitor and improve quality.

• Establish systems and processes to and identify andmitigate risks.

• Ensure appropriately staff are appropriately trainingand supported and implement all necessaryemployment checks for all staff.

Action the service SHOULD take to improve

• Improve arrangements for patients unable tocommunicate their needs in English.

• Consider how to address a patient preference foraccess to a female GP.

• Make arrangements to ensure appropriate monitoringof prescription pads.

• Improve the process for complaints management.

Summary of findings

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Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included a GP specialist adviser, a practicemanager Specialist Adviser and an Expert by Experience.

Background to Dr SurendraKumar DhariwalDr Surendra Kumar Dhariwal (also known as Manor ParkMedical Centre) is situated within NHS Newham ClinicalCommissioning Group (CCG). The practice provides servicesto approximately 1,350 patients under a Personal MedicalServices (PMS) contract.

The practice was registered with the Care QualityCommission (CQC) to carry on the regulated activities ofmaternity and midwifery services, family planning services,treatment of disease, disorder or injury, surgicalprocedures, and diagnostic and screening procedures. Thelead GP told us minor surgery and family planning had notbeen undertaken for a long time. The practice had notapplied to CQC to remove minor surgery or family planningas a regulated activity.

Information from the practice showed some staffingarrangements were ad hoc or could not be determined; thisreport refers to information received directly from thepractice at inspection. Staff include the lead male GP, DrDhariwal, working seven sessions per week, two malelocum GPs (both working one session per week), onefemale practice nurse intended to work one session or dayper week whose attendance was ad hoc and was away forthree months at the time of inspection, a practice secretarywho also assists in managing the practice, who was away at

the time of inspection and works anything up to 35 hoursper week, and two reception staff (one working an amountover 20 hours per week and the other working between 12and 16 hours per week). Dr Dhariwal told us there was alsoa summariser working one day per week at the practice;however there was no record of their attendance (amedical summariser summarises all medical notes andletters to provide healthcare professionals with anaccurate, easily accessible electronic summary of apatient's medical history).

The practice premises are on the ground floor of aconverted semi-detached house. Its core opening hours arebetween 8:00am to 6.30pm every weekday. GPappointments are from 9.00am to 11.00am and 4.00pm to6.00pm, except on Thursday when there is no afternoonsession but the doors of the practice remain open. Thepractice offers on-site extended hours GP appointmentsfrom 6.30pm until 7.00pm on Tuesdays and Fridays.Patients telephoning when the practice is closed aredirected to the local Newham GP Co-op out-of-hoursservice provider. Appointments include pre-bookableappointments, home visits, telephone consultations andurgent appointments for patients who need them.

The practice is located in one of the most deprived areas inEngland and has a relatively high population of olderpatients compared to the local CCG. Data showed 17% ofits patients were over 65 years of age compared to 6%within the CCG and 17% nationally. The average male andfemale life expectancy for the practice is 76 years for males(compared to 77 years within the Clinical CommissioningGroup and 79 years nationally), and 82 years for females(compared to 82 years within the Clinical CommissioningGroup and 83 years nationally).

DrDr SurSurendrendraa KKumarumar DhariwDhariwalalDetailed findings

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Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. The inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

The provider had not been inspected under the currentregulations.

How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 29June 2016.

During our visit we:

• Spoke with the lead GP, the receptionist, and withpatients who used the service.

• Observed how patients were being cared for and talkedwith carers and/or family members

• Reviewed an anonymised sample of the personal careor treatment records of patients.

• Reviewed comment cards where patients and membersof the public shared their views and experiences of theservice.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services were provided forspecific groups of people and what good care looked likefor them. The population groups are:

• Older people• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

Detailed findings

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Our findingsSafe track record and learning

There was no effective system in place for reporting andrecording significant events and the practice did notidentify significant events to carry out analyses or takeaction to improve safety in the practice.

• Staff told us they would inform the lead GP of anyincidents but there was no recording system in place.There was an accident reporting book with a 19 June2016 entry showing the medicines refrigeratortemperature for storing vaccines had gone out of range.However, an infection prevention and control auditcarried out on 13 June identified immediate actionswere necessary to ensure the correct process for storingvaccines but the practice had not addressed this untilsix days later on 19 June 2016.

• There was no evidence that when things went wrongwith care and treatment, patients were informed of theincident, received reasonable support, truthfulinformation, a written apology and were told about anyactions to improve processes to prevent the same thinghappening again.

• The practice provided us with one example of asignificant event dating back to June 2015. However,half of the text was missing and the readable part didnot demonstrate significant events were being learnedfrom effectively to improve patient safety.

We made additional checks on the accident book toestablish if any further significant events had beenrecorded and there were no further entries in the last sevenyears, the next most recent dated back to 2008. There wasno other system or process to report or record incidentsincluding notifiable incidents under the duty of candour.(The duty of candour is a set of specific legal requirementsthat providers of services must follow when things gowrong with care and treatment).

We asked the lead GP about the absence of identifying,reporting, recording and management of significant eventsand they told us it was not possible to record everything.This demonstrated a lack of understanding on theprovider’s part of the role significant event analysis plays inlearning from what went wrong or helping improvepractice.

There were no examples of patient safety alerts or minutesof meetings where these or any other safety issues werediscussed. There was no evidence that lessons werelearned or shared, or that action was taken to improvesafety in the practice.

Overview of safety systems and processes

There were gaps in systems, processes and practices inplace to keep patients safe and safeguarded from abuse:

• Safeguarding policies were accessible to all staff andthey were clear they should contact the lead GP forfurther guidance with any concerns about a patient’swelfare. The lead GP was the lead for safeguarding andstaff demonstrated they understood theirresponsibilities but there was no evidence any staffreceived training from the practice on safeguardingchildren and vulnerable adults relevant to their role,including the practice nurse and locum GPs. The leadGP was trained to both child and adult safeguardinglevel 3.

• A notice in the waiting room advised patients thatchaperones were available if required. However,arrangements were not in place to provide patients witha chaperone should they request one. There was nochaperoning policy, evidence of chaperone training orthat the practice had carried out a recent Disclosure andBarring Service (DBS) check for staff joining the practiceor for any staff that might be called on to act as achaperone. (DBS checks identify whether a person has acriminal record or is on an official list of people barredfrom working in roles where they may have contact withchildren or adults who may be vulnerable). The dutyreceptionist told us that none of the staff werechaperones. We asked the lead GP about chaperoningarrangements especially as all three GPs at the practicewere male and the female practice nurse was away forthree months. They told us the secretary was achaperone, patients were given a choice but did not askfor a chaperone, a chaperone had not been requestedfor two years, and the offer of a chaperone was notrecorded on patients’ notes unless requested.

• The practice did not maintain appropriate standards ofcleanliness and hygiene. A premises cleaning schedulewas in place and had been signed but we observedareas of the premises such as the patient’s toilet andskirting boards to be dusty. Staff told us carpets in thepractice had been cleaned on 16 June 2016 and showed

Are services safe?

Inadequate –––

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us a diary entry with a carpet cleaning flyer for that date;however, the carpets were visibly stained. The lead GPwas the infection control clinical lead and there was aninfection control policy dated 2014. However, there wasno evidence that any staff had been appropriatelytrained according to their role, including the lead GP. Anexternal infection control audit arranged by the NHSNorth East London Commissioning Support Unit hadbeen carried out 13 June 2016 that identified multipleconcerns and actions to be carried immediately orwithin two weeks such as correct colour coding andstorage of cleaning equipment, out of date sharps,syringes and medicines, lack of clinical equipmentcleaning, clutter around the practice, and multiplethermometers in medicines refrigerator each with adifferent temperature reading. None of the sharps boxeswere date labelled, one was broken and guidance onspillages of blood and / or body fluids and sharps,needle stick and splashing injuries had not beenreviewed since October 2003.

• There was no system in place to ensure cleaningequipment was safe to use it was stored in an openboiler cupboard located within the patient’s toilet, alongwith cleaning chemicals such as bleach that was storedon the floor which posed a hazard to patients such aschildren. There was no spillage kit available or Controlof Substances Hazardous to Health (COSHH) protocol inplace and the mop and broom were stood with theheads or handle sticks in between boiler water and / orgas pipes which posed a risk of pipe damage and gas orwater leak. We raised the issue of the unlocked cleaningchemicals cupboard with non-clinical staff and theyfound the key and locked the cupboard on the day ofinspection. After inspection the practice told us thecleaner had said they always lock the cupboard doorbut had purposely left it open for inspection.

• There was no schedule for clinical equipment cleaningand there were multiple items in use that were visiblydirty, such as three peak flow meters and the earirrigator. We discussed this with the infection controllead who told us none of the equipment we had lookedat was in use, that no patients had their ears irrigated(syringed) at the practice, and patients needing thisservice were signposted to an alternative local service.We asked why the equipment was out in a treatmentroom and the infection control lead did not offer anexplanation.

• Not all arrangements for managing medicines, includingemergency medicines and vaccines, kept patients safe.Processes were in place for handling repeatprescriptions which included the review of high riskmedicines. The practice carried out regular medicinesaudits, with the support of the local CCG pharmacyteams, to ensure prescribing was in line with bestpractice guidelines for safe prescribing. Blankprescription forms and pads were securely stored butwe found no systems in place to monitor their use.

• The lead GP provided us with contradictory informationrelating to Patient Group Directions to allow nurses toadminister medicines in line with legislation andarrangements were unclear.

• We found there were five medicines refrigeratorthermometers each with a different temperaturereading. Records showed that temperatures required toassure medicines safety had gone out of range to onedegree Celsius every day since 20 June 2016 (therecommended safe range is between two and eightdegrees Celsius). No action had been taken to checkmedicines’ safety. The lead GP was not able todemonstrate an understanding of how the medicinesrefrigerator thermometer worked and it had not beenreset daily in accordance with the manufacturer’sinstructions. We brought the relevant section to theattention of the lead GP and asked them to seek advicefrom the relevant manufacturers that medicines wereeither safe for use or required disposal, and to confirmactions taken to us the day after inspection. The practicecontacted us two days after inspection and told us ithad been in contact with a company engineer and thecold chain had not been broken as refrigerator alarmwould sound if the thermometer went out of range formore than 15 minutes to indicate further actions beingrequired.

• Systems to recruit were not safe. We reviewed personnelfiles and found appropriate recruitment checks had notbeen undertaken prior to employment. The practice hada recruitment procedure but we found it did not complywith the requirements of the Health and Social Care Act(Regulated Activities) Regulations 2014 and had notbeen implemented. For example, the procedure coveredreference checks but did not state the need for staff DBSor identification checks. The only DBS checks availablewere for a receptionist that were carried out by aprevious employer in 2014. Proof of identification andreferences checks had not been carried out and the

Are services safe?

Inadequate –––

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practice could not provide evidence of indemnity coverfor clinicians. DBS checks for the two locum GPs datedback to 2004 and 2001. However, the practice showed usNHS England national performer list information for thetwo locum GPs, one was dated 20 October 2010 and theother 14 June 2016. (The NHS England performers listsprovide an extra layer of reassurance for the public thatGPs practising in the NHS are suitably qualified, have upto date training, have appropriate English languageskills and have passed other relevant checks such aswith the Disclosure and Barring Service and the NHSLitigation Authority). All clinicians were registered withthe appropriate professional body.

Risks to patients were not assessed or well managed.

• There were no procedures in place for monitoring andmanaging risks to patient and staff safety. There was nohealth and safety policy or premises environmental riskassessment available and the health and safety posterhad not been completed to identify local health andsafety representatives.

• The practice did not have a fire risk assessment, one ofthe fire exits was partially occluded by clutter such as awheelchair and patients notes’ that were in anunsecured patient accessible area. There was noevidence the fire alarm system had been tested orserviced, or notice showing action to be taken in theevent of a fire. Fire extinguishers had been checked on 8June 2016 and there was a log of fire drills whichshowed no evacuation practice had been carried outsince at least October 2015.

• Electrical equipment was not checked to ensure it wassafe to use. Some clinical equipment was checked toensure it was working properly; however, items such asa height measurer and set of baby scales had not beenchecked. There was a blood pressure monitoringmachine at the practice but the printer was not alignedand the printout was missing the first digit which resultswere unreliable.

• The practice had no other risk assessments in place tomonitor safety of the premises such as control ofsubstances hazardous to health and legionella(Legionella is a term for a particular bacterium whichcan contaminate water systems in buildings).

• There was no clear system in place for planning andmonitoring the number of staff and mix of staff neededto meet patients’ needs. The only female clinical staffmember was away for three months and no cover hadbeen arranged.

Arrangements to deal with emergencies and majorincidents

The practice did not have adequate arrangements in placeto respond to emergencies and major incidents.

• There was an instant messaging system on thecomputers in all the consultation and treatment roomswhich alerted staff to any emergency.

• Staff had not received annual basic life support trainingand the lead GP was last trained in 2014.

• Emergency medicines were available in the treatmentroom but some adrenaline had expired in 2013 with theremaining adrenaline due to expire the next day 30 June2016 (emergency adrenaline is used to treat and preventdeath from anaphylactic shock, which is a severeallergic reaction). We brought this to the attention of thelead GP and they told us this was not a problembecause some of the stock was in date. However, theout of date adrenaline had not been removed from thetreatment area or been marked unfit for use and therewas no evidence of forward planning or new adrenalinebeing ordered. This increased the risk of a patient beingadministered an out of date medicine in an emergencysituation. Emergency medicines were easily accessibleto staff and all staff knew of their location, but the out ofdate adrenaline was in an open tray trolley accessible tothe public and at child height, along with sharps andcervical cytology testing sample liquid which ishazardous.

• The practice had a defibrillator available on thepremises which was in working order but there was nosystem to check it remained fit for use. There was noemergency use oxygen with adult and children’s masks.We brought this to the attention of the practice and afterinspection they sent us evidence of it being obtained.

• An accident book and five first aid kits were availablebut most first aid kit dressings were out of date. Forexample some dressings had expired in 2009 and 2010.

Are services safe?

Inadequate –––

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The practice’s business continuity plan in place wascomprehensive and covered major incidents such as powerfailure or building damage but was out of date and had notbeen reviewed since 2008; for example to updateemergency contact numbers for staff.

Are services safe?

Inadequate –––

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Our findingsEffective needs assessment

The practice could not demonstrate it assessed needs anddelivered care in line with relevant and current evidencebased guidance and standards, including National Institutefor Health and Care Excellence (NICE) best practiceguidelines.

• The lead GP told us they attended weekly clinicalmeetings at a local hospital to stay up to date but therewere no records or systems in place to keep all clinicalstaff updated. Staff did not have access to guidelinesfrom NICE to use this information to deliver care andtreatment to meet patients’ needs.

Management, monitoring and improving outcomes forpeople

The practice used the information collected for the Qualityand Outcomes Framework (QOF) and performance againstnational screening programmes to monitor outcomes forpatients. (QOF is a system intended to improve the qualityof general practice and reward good practice). The mostrecent published results were 97% of the total number ofpoints available, with 5% exception reporting.

The practice was not an outlier for any QOF (or othernational) clinical targets, and data from 2014 - 2015showed;

• Performance for diabetes related indicators was 98%which is similar to CCG and national averages (CCGaverage 87%, national average of 89%)

• The percentage of patients with hypertension havingregular blood pressure tests was 91%, which is similar tothe CCG and national averages of 84%

• Performance for mental health related indicators was86%, which was similar to CCG and national averages(CCG average 87%, national average 93%)

The practice did not carry out two cycle audits to improvepatient outcomes, there were none in the preceding twoyears and the two most recent audits were single cycle anddated back to January 2014 and 2013. There was noevidence of any other quality improvement activity.

Effective staffing

Staff did not have the skills, knowledge and experience todeliver effective care and treatment.

• The staff could not demonstrate they had an effectiveinduction programme in place. The practice had aninduction programme dated 2005 for all newlyappointed staff, which covered such topics such as firesafety, health and safety and confidentiality but did notinclude safeguarding or infection prevention andcontrol and had not been implemented, for example fora staff member employed in October 2015 . Staff told usthey had on the job induction including on how to usethe practice computer system but there was nodocumentary evidence of this or checklist for essentialinduction topics covered.

• The practice could not demonstrate how they ensuredrole-specific training and updating for relevant staff. Forexample, for those reviewing patients with long-termconditions.

• The provider could not demonstrate staff administeringvaccines and taking samples for the cervical screeningprogramme had received specific training which hadincluded an assessment of competence. There was noevidence of discussion at practice meetings or staffaccess to online resources to demonstrate staff whoadministered vaccines stayed up to date with changesto the immunisation programmes.

• There was no system in place to identify staff trainingand development needs. For example, the most recentappraisal record we found dated back to 2011.

• All GPs were registered with the GMC and the practiceshowed us NHS England performance list informationfor the two locum GPs, one was dated October 2010 andthe other June 2016.

• Staff had not received training such as safeguarding, firesafety awareness, basic life support and informationgovernance. We found no evidence of staff access toe-learning training modules and in-house training.

Coordinating patient care and information sharing

Information needed to plan and deliver care and treatmentwas not always available to relevant staff in a timely andaccessible way, including through the practice’s patientrecord system and their intranet system. Care plans andrisk assessments were mostly in place, comprehensive andregularly reviewed. However, the practice could notadequately demonstrate it acted on or shared relevantinformation with other services in a timely way. Forexample:

Are services effective?(for example, treatment is effective)

Inadequate –––

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• There was no evidence of any multidisciplinarymeetings with allied health or social care professionals.The lead GP told us this was in the process of beingarranged. Staff had not worked together with otherhealth and social care professionals to understand andmeet the range and complexity of patients’ needs and toassess and plan ongoing care and treatment.

• We asked non-clinical staff how information was sharedbetween the practice and other providers and they werenot able to show us any example of information thatwas shared.

• We checked advance care plans for three frail elderlypatients with dementia and only one had beencompleted. However, we saw three care plans forpatients with diabetes that were appropriate.

• The practice could not show us a recent example ofreviewing care for vulnerable patients such as thosewith mental health problems or frail elderly patientsfollowing their attendance at accident and emergencyor unplanned admission to hospital. The lead GP told usthis had not happened within the last two to three yearsand we found no follow up system in place.

Consent to care and treatment

The practice could not always demonstrate it had soughtpatients’ consent to care and treatment in line withlegislation and guidance.

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005 andassessments of capacity to consent when providing careand treatment for children and young people but couldnot show us any examples.

• The practice could not demonstrate patients had beenoffered informed consent for intimate examinations.The practice was registered to carry out family planningand minor surgery, both requiring patient’s informedconsent but told us it had not carried out suchprocedures for a long time.

• We asked the lead GP to show us an example of a recordof consent for administering a patient’s vaccine. Atemplate was available on the computer system but norecord of patient’s consent had been made. Consenthad been verbal or implied and there was no process tomonitor whether consent had been sought.

Supporting patients to live healthier lives

The practice identified patients who may be in need ofextra support. For example:

• Patients receiving end of life care, carers, and those atrisk of developing a long-term condition. Patients weresignposted to the relevant service.

The practice’s uptake for the cervical screening programmewas 74%, which was comparable to the CCG average of81% and the national average of 82%.

We checked two sets of cervical cytology results requiring arepeat within three months as indicated on the results.Neither had been repeated and we checked the practicecomputer system for one of the results which indicated therepeat was not due until February 2019. In this caseinformation had not been correctly added to the electronicpatient record and this patient was put at risk of a clinicaldiagnosis not being made.

The practice had offered telephone reminders for patientswho did not attend their cervical screening test but therewere no failsafe systems to ensure results were received forall samples sent for the cervical screening programme. Wealso found a cervical cytology result that showed thesample was not adequately labelled and this had not beenaddressed by the practice or identified as a significantevent.

The practice could not adequately demonstrate how theyencouraged uptake of the screening programme becauseall GPs were male and the female practice nurse sampletaker was on leave for least three months. Staff showed usa March 2016 letter to patients demonstrating it hadtelephoned patients requesting they attend for the testwith a choice of two Fridays the same month, after whichcervical screening would not be available until “later in theyear when this service is restored.”

The practice encouraged its patients to attend nationalscreening programmes for bowel and breast cancerscreening.

Childhood immunisation rates for the vaccines given werecomparable to CCG averages. For example, childhoodimmunisation rates for the vaccines given to under twoyear olds ranged from 75% to 88% and five year olds from81% to 100% (CCG ranged from 82% to 95%).

Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74.

Are services effective?(for example, treatment is effective)

Inadequate –––

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Our findingsPatient’s feedback was generally positive but the practicehad not sought and recorded patients consent, or ensuredaccess to a female clinician to sustain continuity of thecervical screening service. The practice premises andequipment was visibly dirty.

Kindness, dignity, respect and compassion

We observed members of staff were courteous to patientsand treated them with dignity and respect.

• Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments.

• We noted that consultation and treatment room doorswere closed during consultations; conversations takingplace in these rooms could not be overheard.

• Reception staff knew when patients wanted to discusssensitive issues or appeared distressed they could offerthem a private room to discuss their needs.

Forty seven of the 48 patient Care Quality Commissioncomment cards we received were positive about theservice experienced. Patients said they felt the practiceoffered an excellent service and staff were helpful andcaring.

We spoke with several members of the patient participationgroup (PPG). They also told us they were satisfied with thecare provided by the practice and said their dignity andprivacy was respected. Comment cards highlighted thatstaff responded compassionately when they needed helpand provided support when required.

Results from the national GP patient survey publishedJanuary 2016 showed patients felt they were treated withcompassion, dignity and respect. The practice wascomparable for its satisfaction scores on consultations withGPs and reception staff. For example:

• 81% said the GP was good at listening to themcompared to the CCG average of 83% and nationalaverage of 89%.

• 94% said the GP gave them enough time (CCG average82%, national average 92%).

• 89% said they had confidence and trust in the last GPthey saw (CCG average 91%, national average 95%).

• 81% said the last GP they spoke to was good at treatingthem with care and concern (CCG average 76%, nationalaverage 85%).

• There was no data available for survey results onwhether the practice nurse was good at treating patientswith care and concern.

• 86% said they found the receptionists at the practicehelpful (CCG average 80%, national average 87%).

Care planning and involvement in decisions aboutcare and treatment

Patients told us they felt involved in decision making aboutthe care and treatment they received. They also told usthey felt listened to and supported by staff and hadsufficient time during consultations to make an informeddecision about the choice of treatment available to them.Patient feedback from the comment cards we received wasalso positive and aligned with these views. We also sawthat most care plans were personalised.

Results from the national GP patient survey showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment. Results were comparable to local andnational averages. For example:

• 83% said the last GP they saw was good at explainingtests and treatments compared to the CCG average of80% and national average of 86%.

• 74% said the last GP they saw was good at involvingthem in decisions about their care (CCG average 74%,national average 82%).

• There was no data available for survey results onwhether practice nurse was good at involving patients indecisions about their care.

The practice provided some facilities to help patients beinvolved in decisions about their care:

• Staff were able to speak languages such as Guajaratiand Bengali to communicate with some patients whodid not have English as a first language, but there wasno notice in the reception area to informing patient’stranslation services were available for other patientswhose first language was not English. Staff told us thesecretary could book a translator if required but thesecretary was away for two weeks and duty staff couldnot explain how the system worked. There was noinformation available in other languages in thereception area. We asked staff how they would manage

Are services caring?

Requires improvement –––

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for a patient that spoke another language and they saidthey would try to explain to the patient to go away andcome back with someone who can speak English. Therewas a multilingual touch screen patients check in but itwas switched off and had been out of use for sevenmonths.

• Information leaflets were available in English in an easyread format.

Patient and carer support to cope emotionally withcare and treatment

Patient information leaflets and notices were available inthe patient waiting area which told patients how to accessa number of support groups and organisations. However,the practice did not have a website.

The practice’s computer system alerted GPs if a patient wasalso a carer. The practice had identified 34 patients ascarers (3% of the practice list). The practice used the list toprovide carers with support such as flu vaccines and healthchecks. Written information was available to direct carersto the various avenues of support available to them.

Staff told us the lead GP provided support to patientsfollowing a family bereavement. There was no formalprocess for when families had suffered bereavement.

Are services caring?

Requires improvement –––

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Our findingsResponding to and meeting people’s needs

The practice reviewed the needs of its local population andengaged with the NHS England Area Team and ClinicalCommissioning Group (CCG) to secure improvements toservices where these were identified. For example, it hadidentified it had a relatively high population of patientswith diabetes and offered enhanced diabetes care for thesepatients.

• The practice offered on-site extended hours GPappointments from 6.30pm until 7.00pm on Tuesdaysand Fridays for working patients who could not attendduring normal opening hours.

• There were longer appointments available for patientswith a learning disability.

• Home visits were available for older patients andpatients who had clinical needs which resulted indifficulty attending the practice.

• Same day appointments were available for children andthose patients with medical problems that require sameday consultation.

• Patients were able to receive travel vaccines availableon the NHS.

• There were some disabled facilities such as ramp accessbut there was no hearing loop. We asked staff how theymanaged communications for people with a hearingimpairment and they said there were none registered atthe practice.

• There was a multi lingual check in screen andinformation for patients but it was out of use.

• Baby changing facilities and a private room forbreastfeeding were available.

Access to the service

The entrance to the practice appeared to be at the front ofthe premises and had a gate that would only half open halfway. The ramp and entrance was mossy and littered. Welater found an A4 sized notice at one side of the practicefront window redirecting patients to the other side of thebuilding and found an unmarked entrance to the practicearound the corner. The door looked like the entrance to adomestic dwelling and there was no signage above thedoor to indicate it was the practice entrance. We discussed

ease of access to the building for patients with issues suchas mobility or visual impairment with the lead GP and theytold us that all patients know how to enter the building anda patient is not a patient until they are registered.

The practice was open between 8.00am and 6.30pmMonday to Friday. Appointments were from 9.00am to11.00am and 4.00pm to 6.00pm except Thursdays whenappointments finished after morning surgery but thepractice doors remained open. Extended hours GPappointments were offered from 6.30pm until 7.00pm onTuesdays and Fridays. Patients telephoning when thepractice is closed were directed to the local Newham GPCo-op out-of-hours service provider. Appointmentsincluded pre-bookable appointments, home visits,telephone consultations and urgent appointments forpatients who need them.

Results from the national GP patient survey showed thatpatient’s satisfaction with how they could access care andtreatment was comparable to or higher than local andnational averages.

• 87% of patients were satisfied with the practice’sopening hours compared to the CCG average of 77%and national average of 78%.

• 95% of patients said they could get through easily to thepractice by phone compared to the CCG average of 61%and national average of 73%.

People told us on the day of the inspection that they wereable to get appointments when they needed them.

Listening and learning from concerns and complaints

The practice a system in place for handling complaints andconcerns but had not managed them effectively.

• Its complaints policy and procedures were in line withrecognised guidance and contractual obligations forGPs in England.

• The lead GP was the designated responsible personwho handled all complaints in the practice.

We looked at three complaints received in the last 12months, one in detail and found these were dealt in atimely way. But the practice had not sought to ensure thecomplaint was resolved from the complainant’s

Are services responsive to people’s needs?(for example, to feedback?)

Requires improvement –––

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perspective. We found no evidence lessons were learntfrom individual concerns and complaints and there was noanalysis of trends or resulting actions taken to improve thequality of care.

Are services responsive to people’s needs?(for example, to feedback?)

Requires improvement –––

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Our findingsVision and strategy

• The practice did not have a mission statement, forwardvision or strategy.

Governance arrangements

The practice governance framework did not support thedelivery of safe or effective care:

• Basic safety requirements had not been identified oraddressed such as fire safety, health and safety orLegionella, and arrangements for managing medicines

• The practice did not maintain systems for staff trainingor appropriate standards of premises or equipmentcleanliness and hygiene, and there was no evidence oflearning or improvement from complaints or significantevents.

• Patient’s medical notes were left out behind a glazeddoor immediately adjacent to consulting rooms. Thedoor was not locked or otherwise indicated as a privateor staff only area. Patient's medical notes wereunsecured and publicly accessible. The lead GP told usa summariser attended the practice once per week tosummarise the notes but we found no evidence of theirattendance and estimate at least fifty sets of notespatients notes we either open or in an unlocked chest ofdrawers within the same area. A member of staff wasregistered as a patient and the practice had no systemin place to assure the confidentiality of their medicalrecords within the staffing team.

• The practice could not show us an example todemonstrate patients had been offered informedconsent for intimate examinations. Consent had beenverbal or implied and there was no process to monitorwhether consent had been sought.

• There was no staffing structure and some staffingarrangements had gaps, or were irregular orindeterminate such as practice nursing and summariserstaffing. Actions to cover the practice nurses threemonth period of leave were limited to asking otherpractices. No cover had been arranged resulting in maleonly clinicians staffing at the practice for three monthsand chaperoning arrangements were ineffective.

• Practice specific policies and procedures were missing,insufficient, out of date, or not implemented. Forexample, the infection control policy, chaperoning

policy, recruitment policy, induction procedure, andguidance on spillages of blood and / or body fluids andsharps, needle stick and splashing injuries dated back toOctober 2003.

• The practice had requested deferment of inspection dueto overlapping absence of nursing and administrativestaff, and it told us this was the reason informationcould not be produced at inspection. The reasons givenfor deferment did not fit the criteria for postponementand practices would be expected to function at all timesin periods of absence. The practice had planned toallow overlapping absence of multiple and key staff, itreceived two weeks’ notice of inspection and the lack ofinformation sharing arrangements in their absencedemonstrated that systems and structures did notunderpin safe and effective continuity of care. Forexample, there were no failsafes for cervical screening,and follow up of cervical screening was ineffective andshould always be maintained. The practice would alsohave had time after the inspection to send in any furtherinformation that was not found on the day.

• Filing systems within the practice were disorganised andwe found various documents mixed together in placesuch as patients cervical screening test results, with nolabelling or indexing system in place, an order forconsumables such as gloves, patients vaccines recordsfrom 2015, a confidential solicitors letter, a clinicalsupervisors letter, a photocopy of someone’s 2014passport, and a contract for shredding of confidentialinformation.

• Arrangements for identifying, recording and managingrisks, issues and implementing mitigating actions wereabsent or had weaknesses. For example there was a lackof identification and management of significant events,there was no health and safety or fire risk assessmentand failsafes for patients’ cervical cytology screeningwere absent.

• Arrangements relating to Patient Group Directions toallow nurses to administer medicines in line withlegislation and arrangements were unclear. The lead GPtold us the practice nurse administered children’svaccines which meant they would need Patient GroupDirections to allow nurses to administer medicines inline with legislation but we found none at the practice.We brought this to the attention of the lead GP and theythen told us Patient Group Directions (PGDs) were notneeded because the practice nurse did not administerany vaccines. We checked nurse’s appointments for the

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Inadequate –––

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preceding two months and found all appointmentswere for cervical screening only. After inspection thepractice told us they had located the PGDs but did notsend us any documentary evidence of them being inplace.

Leadership and culture

The lead GP did not demonstrate they had the experienceor knowledge and skill to run the practice and ensure highquality care. For example, identification of and learningfrom significant events was inadequate and when we askedthe lead GP about the absence of reporting, recording andmanagement of significant events and how learning wasshared in the practice they told us it was not possible torecord everything and asked “who do I share with?”. Therewere several other areas of concern including a lack qualityimprovement process such as continuous clinical andinternal audit or strategy and forward planning.

The provider had no systems to ensure compliance withthe requirements of the duty of candour. (The duty ofcandour is a set of specific legal requirements thatproviders of services must follow when things go wrongwith care and treatment).There was no support training forstaff on communicating with patients about notifiablesafety incidents. The practice could not demonstrate itencouraged a culture of openness and honesty inmanaging either significant events or complaints.

The practice did not have systems in place to ensure thatwhen things went wrong with care and treatment it gaveaffected people reasonable support, truthful informationand a verbal and written apology.

Leadership and management arrangements were unclearbut staff felt supported by management.

• Reception staff were aware of their own roles andresponsibilities and told us the lead GP was responsiblefor all areas including QOF, complaints, infectioncontrol, safeguarding, and personnel/ HR matters.However, the lead GP told us they sharedresponsibilities with the practice secretary and thepractice nurse.

• There were no team meetings, strategic plans oroperational action plans.

• The practice was not undertaking minor surgery orfamily planning and had not applied to CQC to removethese regulated activities from its registration.

• Staff told us there was an open culture within thepractice and they had the opportunity to raise anyissues and felt confident and supported in doing so.

• Staff said they felt respected and valued and supportedbut they were not involved in discussions about how torun and develop the practice.

Seeking and acting on feedback from patients, thepublic and staff

The practice encouraged feedback from patients.

• The practice had met with the patient participationgroup (PPG) and gathered feedback from patientsthrough surveys. The Patient Participation Group (PPG)met every three months and received information fromthe practice but had not carried out patient surveys orsubmitted proposals for improvements to the practicemanagement team. There was no evidence of a processfor quality improvement.

• We found no evidence the practice had gatheredfeedback from staff but staff told us they would nothesitate to give feedback and discuss any concerns orissues with colleagues and management.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Inadequate –––

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Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Termination of pregnancies

Treatment of disease, disorder or injury

Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

How the regulation was not being met: ha

The practice had not sought and recorded patientsconsent.

This was in breach of regulation 11(1) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

How the regulation was not being met:

The registered person did not do all that was reasonablypracticable to assess, monitor, manage and mitigaterisks to the health and safety of service users.

The practice was not appropriately prepared to deal witha medical emergency. For example, emergencyequipment, medicines and dressings were either notprovided or not fit for use

Medicines and clinical equipment such as sharps wereout of date, and there were multiple infection controlconcerns such as no spillage kit or management ofcleaning equipment such as mops.

Electrical equipment was not checked to ensure it wassafe to use and clinical equipment was checked toensure it was working properly.

The registered person did not do all that was reasonablypracticable to assess, monitor, manage and mitigaterisks to the health and safety of service users.

Regulation

Regulation

This section is primarily information for the provider

Enforcement actions

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There were no examples of patient safety alerts orminutes of meetings where these or any other safetyissues were discussed.

Arrangements were not in place to assure the safemanagement of medicines such as refrigeratedmedicines.

This was in breach of regulation 12(1) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

How the regulation was not being met:

Premises and equipment were visibly dirty and cleaningschedules were absent or ineffective.

The practice was cluttered, one of the fire exits waspartially occluded and premises fire safety arrangementswere inadequate.

The entrance to the practice was unclear and hazardousand some examination couches were not fit for purpose.

This was in breach of regulation 15(1)(2) of the Healthand Social Care Act 2008 (Regulated Activities)Regulations 2014.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

How the regulation was not being met:

Systems and processes for significant eventsidentification and management, receiving anddisseminating safety alerts, acting on safety alerts, andensuring staff were up to date with best practiceguidelines were absent or ineffective.

Regulation

Regulation

This section is primarily information for the provider

Enforcement actions

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The provider person did not seek and act on feedbackfrom relevant persons for the purposes of continuallyevaluating and improving such services.

The provider had not ensured effective arrangements forpatients chaperoning or maintenance of failsafe systemsfor patient’s cervical cytology results.

The provider did not ensure effective informationsharing and patient care co-ordination such asmultidisciplinary meetings.

The provider did not make appropriate arrangements forpatients chaperoning or to seek and/ or record patient’sconsent.

The provider did not have effective systems in place toassess, monitor and mitigate risks.

There were systemic weaknesses in governance systemsincluding ineffective monitoring of procedures such asinduction and Guidance for “spillages of blood and / orbody fluids” and “Sharps, Needle stick and SplashingInjuries”

The provider had not maintained security of patient’sconfidential information.

The provider had not ensured the leadership had theexperience, knowledge or skill to run the practice andensure high quality care.

This was in breach of regulation 17(1) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 18 HSCA (RA) Regulations 2014 Staffing

How the regulation was not being met:

Sufficient numbers of suitably qualified, competent,skilled and experienced persons had not been deployedsuch as there were gaps in staff cover, induction,appraisal and training.

This was in breach of regulation 18(2) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulation

This section is primarily information for the provider

Enforcement actions

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Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

How the regulation was not being met:

The provider had failed to maintain all the informationrequired in respect of persons employed or appointedfor the purposes of a regulated activity, as set out inSchedule 3 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.

This was in breach of Regulation 19 (3)(a) of the Healthand Social Care Act 2008 (Regulated Activities)Regulations 2014.

Regulation

This section is primarily information for the provider

Enforcement actions

28 Dr Surendra Kumar Dhariwal Quality Report 03/11/2016