This practice is rated as Inadequate overall. (Previous inspection November 2017 – Requires Improvement).

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced focused inspection at Dr Antoine Sayer (also known as Richmond Green Medical Centre) on 3 July 2018. This inspection was carried-out to follow up on breaches of regulations identified at the previous inspection in November 2017. During day one we identified areas where further evidence was required to ensure that the care being delivered was safe and effective, and the decision was made that the scope should be extended to become a comprehensive inspection. We therefore returned to the practice on 12 July 2018 to collect the further evidence and to inspect areas not originally included as lines of enquiry.

At this inspection we found:

• The practice had some systems to manage risk so that safety incidents were less likely to happen; however, when safety risks were identified, these were not always well addressed. When incidents did happen, the practice learned from them and improved their processes.
• The practice had equipment and arrangements in place to deal with medical emergencies; however, they did not have medicines available to treat a patient having a seizure. The practice had provided their reception staff with guidance about when patients should be prioritised for medical attention; however, they had not provided training on how to identify the symptoms of sepsis.
• Staff at all levels were aware of their responsibilities in respect of safeguarding; however, one member of the clinical team had not completed safeguarding training within the guideline timescale.
• The practice carried-out some reviews of the effectiveness and appropriateness of the care it provided; however, there were some areas, such as antibiotic prescribing, where the practice’s review was insufficient to provide assurance that the care being provided was safe and appropriate.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Structures, processes and systems to support good governance and management were not always clearly set out, understood and effective. For example, the practice did not have clear processes for the handling of incoming patient information (e.g. test result and hospital letters); each clinician had their own process, and the provider had failed to ensure that these processes were safe and effective.

The areas where the provider must make improvements as they are in breach of regulations are:

• Systems or processes must be established and operated effectively to ensure good governance.
• Provide care and treatment in a safe way for service users

The areas where the provider should make improvements are:

• Review arrangements in place to enable staff to respond to medical emergencies, in particular, the emergency medicines available, and the ability of reception staff to identify patients with sepsis.
• Review arrangements for monitoring when staff are due for mandatory training updates.

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 population group, 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.

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

Letter from the Chief Inspector of General Practice

This practice is rated as Requires improvement overall. (Previous inspection March 2015 overall rating – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students) – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Dr Antoine Sayer (also known as The Richmond Green Medical Centre) as part of our inspection programme.

At this inspection we found:

• Risks associated with the practice’s processes were not always fully recognised and addressed. In particular, the practice’s arrangements for triaging patients for appointments, managing prescription stationary and uncollected prescriptions, and ongoing review and management of patients’ conditions required further consideration in order to manage risks.

• The practice had failed to carry-out activities to assure themselves that the care and treatment provided to patients was effective and delivered in line with current evidence-based guidance.
• Feedback received from patients suggested that they felt staff at the practice were caring. However, the practice needed to do more to identify patients with caring responsibilities.

• The practice had some understanding of their patient population, but they had not done enough to tailor their services to address the needs of this population; for example, they had identified that they had a large proportion of working-age patients, but they did not provide extended hours appointments, there was no female cervical screening sample-taker available, and their appointment system did not set aside appointments for same-day bookings.
• There was a lack of governance arrangements to ensure that risk was managed and that quality assurance processes were in place which led to improvements in patient oucomes.

The areas where the provider must make improvements are:

• The practice must ensure systems and processes are established and operated effectively to demonstrate good governance.
• The practice must put processes in place to ensure that care and treatment is provided in a safe way for service users.

In addition, the provider should make improvements in the following areas:

• They should take action to increase the number of carers identified, in order that they can provide support to these patients.
• They should take action to increase the uptake of childhood immunisations.
• They should share details of all complaints and significant events with all members of staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

The Richmond Green Medical Centre provides GP services to just approximately 2,000 patients across Richmond, Sheen and parts of Twickenham. The practice has a branch surgery in Putney but this was not visited as part of this inspection.

We carried out a short notice announced comprehensive inspection on 11 March 2015. Overall the practice is rated as good. Specifically, we found the practice to be good at providing effective, caring, responsive and well led services. It was also rated good for the services it provided for all population groups. However, the practice requires improvement for providing safe services.

Our key findings were as follows:

• We found the practice was caring. Patients said their privacy was respected, that staff spoke with them appropriately and that they received appropriate care and treatment and that the doctor or nurse explained any treatment to them clearly. Patients said the repeat prescription process worked for them.
• We found the practice was responsive to patients’ needs. They used information from patient surveys, comments and complaints to improve the services provided. The practice was accessible to people with mobility problems and those who used baby pushchairs. There was a range of on the day urgent and bookable in advance appointments; home visits were provided when required. Information about how to make a complaint was displayed at the practice.
• We found the practice was effective. Clinical staff referred to best practice guidance and used local prescribing protocols. Staff had access to training, support and had an annual appraisal. Suitable systems were in place to work with other health and social care providers.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Suitable arrangements were in place for staff recruitment and infection control.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Ensure the systems in place to deal with high risk medicines as part of the repeat prescription service are clear and understood by locum GPs;
• Ensure all GPs complete regular updates in child protection with records available at the practice;
• Record multidisciplinary meetings and
• Improve information about complaints so all patients are aware of the process.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Our inspection of 14 February 2014 found that: the systems for dealing with medical emergencies were inadequate because there was no emergency oxygen available; patients were not being sufficiently protected from the risk of infection because the provider did not have effective arrangements in place to minimise the risk and spread of infection and patients were not always protected against the risks associated with medicines because the arrangements for storage were not safe and secure. The provider wrote to us and told us that they would make the required improvements by 30 April 2014.

We saw that improvements had been made because emergency oxygen was available; changes had been made to the cleaning schedule and the hot water provision to reduce the risk of infection to patients and medication was securely stored. This meant that patients were protected and were receiving a safer service from the provider.

As part of our inspection we spoke with ten people who used the practice and/or their relatives. We spoke with one doctor, the practice manager, a nurse and two receptionists.

People we spoke with told us they were treated with courtesy and respect at the practice. They confirmed that doctors and staff explained their care and treatment to them, so they were able to give informed consent to any medical intervention. One person remarked "I have a very good relationship with my doctor, I'm a regular and they really understand my needs".

We saw training certificates, which showed staff had received learning and development on the protection of children and on how to recognise and be aware of child abuse.

There was a lack of effective systems in place to reduce the risk and spread of infection. We found that there was no hot water available from all but two sinks. We found the floor and some surfaces in the first floor treatment room to be dirty and dusty.

The practice stored vaccinations in the fridge in the treatment room. However, there was no lock on the fridge or the door to the treatment room to protect from unauthorised access.

There were enough qualified, skilled and experienced staff to meet people’s needs. The majority of the people we spoke with told us that if required, they felt confident the doctor would "see them" and "find an appointment" under urgent situations.

The previous 'patient survey' showed that while people using the service had been involved in some feedback about some aspects of the service, it was unclear how consistently this occurred. A suggestion box was available at reception for people to leave their comments. One person said "I've no issues or reason to complain" and "I've recommended the service to others".