We carried out an announced comprehensive inspection at C. B. Patel & Partners (Hayes Medical Centre) on 29 January 2019 as part of our inspection programme.

At the last inspection in April 2015 we rated the practice as good overall. Previous reports on this practice can be found on our website at: https://www.cqc.org.uk/location/1-551034159.

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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• Risks to patients were assessed and well managed in some areas, with the exception of those relating to safety alerts, some safeguarding procedures, infection control procedures and the management of legionella.
• The practice did not have appropriate systems in place for the safe management of medicines.
• There was an ineffective system in place to monitor the use of blank prescription forms for use in printers and handwritten pads.
• The practice had not carried out premises health and safety risk assessment and some fire safety procedures were not appropriately managed.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, we noted there was a lack of communication and the practice had not widely shared lessons learned from significant events to improve safety in the practice.
• Recruitment checks were not always carried out in accordance with regulations or records were not kept in staff files.

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

• The practice’s performance on quality indicators related to patients with diabetes was below the local and the national averages. The practice had taken steps to improve the outcomes for patients with diabetes, however, it was too early to assess the impact of these improvements.
• The practice’s uptake of the national screening programme for cervical and bowel cancer screening and childhood immunisations rates were below the national averages.
• There were no failsafe systems to follow up women who were referred as a result of abnormal results after cervical screening.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
• Staff had received the appropriate training and appraisal necessary to enable them to carry out their duties.

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

• Feedback from patients reflected that they were not always able to access care and treatment in a timely way.
• The practice was encouraging patients to register for online services and 49% of patients were registered to use online Patient Access.
• Information about services and how to complain was available. However, some information was not up to date.
• The practice organised and delivered services to meet patients’ needs.

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

• There was a lack of good governance.
• Clinical lead responsibilities were not always shared with other clinicians.
• The practice had not appointed a dedicated clinical lead to oversee the management of test results and there was no monitoring system in place to ensure that patient correspondence across the practice was managed in a timely manner.
• There was no formal monitoring system for following up patients experiencing poor mental health and patients with dementia who failed to collect their prescriptions in a timely manner; or to identify and monitor who was collecting the repeat prescriptions of controlled drugs from reception.
• There was no formal supervision arrangement in place to monitor the clinical performance and decision making of a nurse prescriber employed by the practice.
• Most policies and protocols did not include name of the lead member of staff including adult and child safeguarding policies. Most of the policies did not include the name of the author and they were not dated so it was not clear when they were written or when they had been reviewed.
• The practice was aware of and complied with the requirements of the Duty of Candour.
• Staff we spoke with on the day of inspection informed us they felt supported by the management.

These areas affected all population groups so we rated all population groups as requires improvement.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

• Review formal sepsis awareness training needs for non-clinical staff to enable them to identify patients with severe infections.
• Consider ways to improve the identification of carers to enable this group of patients to access the care and support they need.
• Consider displaying information about a translation service in the reception area informing patients this service is available. Review the availability of information posters and leaflets in multiple languages.
• Review the complaint policy and procedures and consider a response to complaints includes information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response.
• Consider reviewing the practice’s website to see if it meets patients needs and expectations.
• Consider how the accessible toilet is accessed in the event of an emergency.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of CB Patel and Partners on 29th April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for the care provided to older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

• Arrangements were in place to ensure patients were kept safe. For example, staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses
• Patients’ needs were suitably assessed and care and treatment was delivered in line with current legislation and best practice guidance.
• We saw from our observations and heard from patients that they were treated with dignity and respect and all practice staff were compassionate.
• The practice understood the needs of their patients and was responsive to them. There was evidence of continuity of care and people were able to get urgent appointments on the same day.
• There was a culture of learning and staff felt supported and could give feedback and discuss any concerns or issues with colleagues and management

However, there were also areas of practice where the provider should make improvements:

• The practice should ensure that all staff that act as chaperones receive chaperone training.

• The practice should ensure that references for all staff are sought before staff start work at the practice.

• The practice manager should ensure they have the appropriate training to carry out their duties as fire marshal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our Inspection of 11 February 2014 found that whilst safeguarding procedures were in place at the practice, staff had not received adequate training to recognise the signs of possible abuse in both children and adults. Some staff we spoke with were not aware of the whistleblowing procedures to follow if needed.

Following the inspection the provider sent an action plan that set out target dates for the completion of safeguarding training for all staff employed at the practice.

During our inspection of 15 April 2014 we saw evidence which demonstrated that each member of staff had completed safeguarding training applicable to their role. Staff we spoke with described a good understanding of safeguarding procedures, including how to escalate any concerns. Staff also demonstrated that they were aware and understood the whistleblowing procedures to follow if they needed to raise any concerns.

During our inspection we spoke with four people using the service, the manager, three doctors, a nurse and six other staff. We viewed two medical records and seven staff files. People we spoke with had mixed opinions about the service. One person said, "all four doctors are very good." Another person said, "they don't always explain things in sufficient detail." All the people we spoke with said staff were usually polite and well mannered. People said it was not always easy to get an appointment over the telephone and they had to come in to the practice to get one although the situation had improved recently.

Safeguarding procedures were in place. However, staff had not received adequate training to recognise the signs of possible abuse in both children and adults and most staff were not aware of the whistleblowing procedures of the service.

Staff had received adequate support and training to ensure they were able to meet the needs of people using the service.

Systems were in place to monitor the standards of care and treatment provided including annual satisfaction surveys and clinical audits. Where shortfalls were identified, improvements to the service had been made although further improvements were necessary.