Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Joseph on 7 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Dr Joseph on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 31 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 7 July 2016. This report covers our findings in relation to those requirements.

Our key findings were as follows:

• The practice sought feedback from staff and patients; however, the principal GP did not always take account of these results or act on them.
• Patients said they were treated with compassion, dignity and respect. However, they did not always feel they were listened to by clinical staff.
• The practice did not have a governance framework to support the delivery of good, personalised care.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However the Practice Nurse had not had induction training.
• Data showed patient outcomes were comparable to the national average.
• No new audits had been carried out since the last inspection and we saw no evidence that audits were driving continuous improvement to patient outcomes.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services being provided by developing clinical quality improvement activity an on-going audit programme of clinical areas.
• Ensure recruitment procedures and policies are established and operated effectively, such as obtaining references and the appropriate checks through the Disclosure and Barring Service, to confirm that staff employed are of good character.
• Ensure that all new staff have completed a comprehensive induction process.
• Put systems in place to improve and monitor patient satisfaction so that it is in line with national survey results.

The areas where the provider should make improvement are:

• Consider the provision of more management support to improve leadership and support to staff. Review the availability of nurse appointments to see if it is sufficient to meet patients’ needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Joseph’s practice on Thursday 7 July 2016. Overall, the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed. However not all staff had received training in fire safety and health and safety.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Data showed patient outcomes were comparable to the national average.
• Although audits had been carried out, we saw no evidence that audits were driving continuous improvement to patient outcomes.
• Patients said they were treated with compassion, dignity and respect. However, they did not always feel they were listened to by clinical staff.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However, they did say they wanted more female GP appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by the practice manager.
• The practice proactively sought feedback from staff and patients; however, the registered manager did not always take the results of these seriously or act on them.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure effective governance arrangements are implemented, including systems for assessing and monitoring risks to patients and acting on feedback to continually improve services.
• Implement a programme of quality improvement including audits to show improvements in patient outcomes.

The areas where the provider should make improvement are:

• Ensure there are effective systems in place to monitor and manage medicines and emergency equipment in the practice to keep patients safe.
• Review systems to identify carers in the practice to ensure they receive appropriate care and support.
• Put systems in place to improve and monitor patient satisfaction so that it is in line with national survey results.
• Ensure all staff receive and complete required training to carry out their roles effectively.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Joseph Surgery Centre on 16 and 21 January 2019

At this inspection we followed up on breaches of regulations identified at a previous inspection on 31 August 2017.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• There were inadequate systems to assess, monitor and manage risks to patient safety.
• Staff did not have the information they needed to deliver safe care and treatment and this posed a serious risk of harm to patients
• Patients were put a serious risk of harm as a result because the practice did not have systems for the appropriate and safe use of medicines
• The practice did not have a system to learn and make improvements when things went wrong.
• Patients were put at serious risk of harm because national safety alerts were not being actioned and implemented by the practice.
• There were ineffective systems to assess, monitor and manage risks to patient safety.
• Recruitment checks were not carried out in accordance with regulations (including for agency staff and locums).
• The practice did not have a health and safety or premises risk assessment to ensure the building is safe for use by staff and patients.

We rated the practice as inadequate for providing effective services because:

• The evidence of summaries of patient problems within patients’ records being incomplete and failure to appropriately clinically code patients, take action for medicine safety alerts. or follow up patient referrals and identify a serious clinical event demonstrated the practice did not have the systems and processes in place to assess and meet patients immediate and ongoing needs or regularly review and update their care and treatment.
• There was limited monitoring of the outcomes of care and treatment. Clinical coding is required to provide accurate quality and outcomes framework (QOF) results. The lack of Clinical coding of patients healthcare needs meant that the QOF figures may not be a true reflection of the practice population healthcare needs. (Quality and Outcomes Framework (QOF) was a voluntary incentive scheme for GP practices in the UK. The scheme financially rewards practices for managing some of the most common long-term conditions e.g. diabetes and implementing preventative measures. The results were published annually.)

• The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Staff did not work together and with other organisations to deliver effective care and treatment.
• Staff were not consistent and proactive in helping patients to live healthier lives

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

• The practice did not have clear and effective processes for identifying, managing and mitigating risks to patients and staff.
• The practice did not act on or maintain appropriate and accurate patient information.
• The overall governance arrangements were ineffective.
• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.

These areas affected all population groups so we rated all population groups as inadequate.

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

• Staff treated did patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people. However, we found some patients were not given appropriate and timely information to cope emotionally with their care, treatment and condition.
• Patients were not always provided with the necessary information to enable them to be fully involved in decisions about care and treatment.
• Although the GP survey showed some improvements from the August 2017 report, the 2018 GP survey results were considerably lower than the CCG and national averages.

The practice was rated requires improvement for providing a responsive service because: -

• The findings in safe, effective and well led have impacted on the practice’s ability to provide a responsive service.
• The evidence of summaries of patient healthcare needs within patients’ records being incomplete and failure to appropriately clinically code patient’s full diagnosis demonstrated the practice did not have the systems and processes in place to fully understand the needs of the patient population groups and respond to them appropriately.
• The practice did not have the ability to organise and deliver a service to meet patient needs.

On the basis of our findings we made an application to Barkingside Magistrate’s Court on 25 January 2019 to urgently cancel the provider’s registration under section 30 of The Health and Social Care Act 2008 on the basis that there were breaches of the 2014 Regulations which presented serious risks to people's life, health or well-being.

The provider’s registration was cancelled with immediate effect subject to the providers right to appeal.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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