We carried out an announced comprehensive inspection at Dr SKS Swedan & Partner on 14 December 2018.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 21 November 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 Requires improvement overall.

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

• Patients received effective care and treatment that met their needs but there was limited action to improve the quality of clinical care.

These areas affected all population groups so we rated all population groups Requires improvement.

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

• There were divides within the GP Partner team and way the practice was led did not consistently promoted a culture of high-quality, person-centre care. Ongoing staff underperformance issues had not been addressed.

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

We rated the practice as good for providing safe, caring and responsive services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Sustain and improve arrangements for gathering patient’s feedback such as the Patient Participation Group (PPG) and a practice led patient satisfaction evaluation and improvement process.
• Review and improve elements of mental health quality and outcomes framework (QOF) performance.

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. (Previous inspection 23 January 2017– Inadequate )

The key questions are rated as:

Are services safe? –Requires Improvement

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? –Requires Improvement

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 inspection at Dr SKS Swedan and Partner on 21 November 2017. This was a comprehensive inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. The practice had been placed in special measures following an inspection on 23 January 2017. Following the inspection the practice were served with a warning notice for Regulation 17. A further follow up inspection to the warning notice was carried out on 15 September 2017 to check that the practice were meeting the requirements of the warning notice. That inspection found that the practice had met all the requirements of the warning notice.

At this inspection we found:

• The practice had not followed their systems to manage risk so that safety incidents were less likely to happen.

• The partners at the practice had previously been in dispute .During this inspection they demonstrated that they were working to resolve their differences and had the British Medical Association (BMA) mediating and supporting them.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was now a focus on continuous learning and improvement at all levels of the organisation.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Results from the national GP patient survey showed patients had responded not so positively for responses related to being treated with compassion, dignity and respect. These scores had reduced since our last inspection. The practice had implemented some changes but were still to address the majority of concerns.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Maintain adequate staffing for the provision of a safe service.

• Maintain the current effective working arrangements between the GP Partners.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 focused inspection of Dr SKS Swedan & Partner on 10 May 2016 and rated the practice as inadequate for safe and well-led services, requires improvement for effective, caring and responsive and an overall rating of inadequate. The provider was placed into special measures. A follow-up announced comprehensive inspection was undertaken on 23 January 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 10 May 2016. At that inspection we found that insufficient improvements had been made and the provider remained rated as inadequate for safe and well-led services. In line with our enforcement procedures we issued a warning notice in relation to regulation 17: Good Governance of the Health and Social Care Act 2008. 

We carried out an announced focused inspection of Dr SKS Swedan & Partner on 15 September 2017. This was to follow-up on a warning notice the Care Quality Commission served following the announced comprehensive inspection on 23 January 2017. The warning notice, issued on 7 March 2017, was served in relation to regulation 17: Good Governance of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notice was 12 May 2017.

The inspection on 23 January 2017 highlighted several areas where the provider had not met the standards of regulation 17: Good Governance. We found:

• The provider was failing to assess, monitor and mitigate the risks to patients arising from cervical screening tests being carried out but test results not being received.

• The provider was failing to ensure effective systems for staff employment checks.

• The provider was failing to operate effective systems to assess, monitor and mitigate Infection Prevention and Control (IPC) risks.

• The Practice Manager was off duty for an indeterminate period and there were no systems in place for ensuring emails sent directly to the Practice Manager were being redirected and dealt with by someone else in the practice.

• The provider was failing to operate effective systems to assess, monitor and mitigate fire safety risks. 

• The provider was failing to operate effective systems to monitor and improve the quality of services such as customer care. 

At this inspection on 15 September 2017 we found that actions had been taken to improve the provision of well-led services in relation to the warning notice. Specifically:

• The practice had reviewed and revised its systems and processes to ensure a fail-safe system for managing cervical screening.
• The practice had reviewed its recruitment policy and systems to ensure appropriate employment checks were carried out.
• The practice had addressed the recommendations of the Infection Prevention and Control (IPC) audit identified at the previous inspection.
• The practice had engaged an interim practice manager three days per week and were in the process of recruiting for a substantive post.
• The practice had reviewed its systems to assess, monitor and mitigate fire safety risks.
• The practice had delivered customer service training for its reception staff and engaged with the Patient Participation Group (PPG).

Our inspection on 15 September 2017 focussed on the concerns giving rise to a warning notice being issued on 7 March 2017. We found that the provider had taken action to address the breaches of regulation set out in the warning notice. However, the current rating will remain until the provider receives a further comprehensive inspection to assess the improvements achieved against all breaches of regulation identified at the previous inspection.

The comprehensive report of the 23 January 2017 inspection which was published on 11 May 2017 should be read in conjunction with this report.

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 SKS Swedan & Partner on 10 May 2016 and rated the practice as inadequate for safety and well-led, requires improvement for effective, caring and responsive and an overall rating of inadequate. The provider was placed into special measures and the full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr SKS Swedan & Partner on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 23 January 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 10 May 2016. This report covers our findings in relation to those requirements. The overall rating from this visit was requires improvement. Our key findings across all the areas we inspected were as follows:

• There was limited staff cover and failsafe systems to ensure results were received for all samples sent for the cervical screening programme had lapsed.
• Most arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were effective but some had gaps such as recruitment, fire safety and infection control.
• Patients did not always find it easy to make an appointment or get through to the practice by telephone.
• There were concerns around staffing such as conduct and time keeping that had not been managed.
• Not all patients treated with dignity and respect. However, patients said they were involved in decisions about their care and treatment.
• Patient Participation Group (PPG) members were happy with the clinical care they received from GPs but raised concerns relating to leadership and governance at the practice.
• There was evidence of systemic problems such as breakdowns in working relationships and divides between staff.
• The leadership team did not consistently demonstrate they had the experience, capacity and capability to run the practice and ensure high quality care.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The provider was aware of and complied with the requirements of the duty of candour.
• Staff had been trained and demonstrated relevant skills, knowledge and experience to deliver effective care and treatment, with the exception of infection control.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance and there was evidence of staff appraisals and personal development plans.
• Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider must make improvements are:

• Ensure effective systems to assess, monitor and mitigate risks to patients such as cervical screening, staff employment checks, and infection prevention and control.
• Implement effective systems and processes for fire safety and arrangements for receiving and acting on communications in the event of staff absence.
• Implement clear and effective systems to run the practice and monitor and improve the quality of services such as patient care.

The areas where the provider should make improvements are:

• Take effective action in response to feedback from relevant persons including GP patient survey results and the PPG to continually evaluate and improve services.

This service was placed in special measures after our previous inspection our previous inspection on 10 May 2016. Insufficient improvements have been made such that there remains a rating of inadequate for well led. Therefore we are taking action in line with our enforcement procedures to second a Warning Notice under Reg 17 as the majority of previous issues under safe are addressed but a poor working culture persists and systems and processes are still lacking. 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

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 SKS Swedan and Partner on the 10 May 2016. Overall the practice is rated as inadequate.

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

• Some systems and processes had weaknesses or were not in place to keep patients safe. For example, the chaperoning policy and arrangements for reporting and preventing accidents and incidents were not robust.
• Medicines were not always managed safely and effectively. For example refrigerated medicines and Patient Group Directions to allow nurses to administer medicines in line with legislation.
• There were gaps in staff training and the induction programme including fire safety, infection control, annual basic life support and safeguarding.
• Practice performance had been affected by insufficient levels of staffing.
• There was evidence of systemic problems such as breakdowns in working relationships and divides between staff, including the leadership team.
• The leadership team did not consistently demonstrate they had the experience, capacity and capability to run the practice and ensure high quality care.
• Patients were generally positive about their interactions with staff and said they were treated with compassion and dignity.
• The provider was aware of and complied with the requirements of the duty of candour and the partners encouraged a culture of openness and honesty with patients.
• The practice acted on feedback from patients through the Friends and Family test. However, engagement and activity with the patient participation group was limited to one meeting annually.
• Patients generally said they found it easy to make an appointment with a named GP and urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

The areas where the provider must make improvements are:

• Implement effective chaperoning arrangements and document patient’s consent for intrauterine contraceptive device (IUCD, also known as 'the coil') and minor surgery procedures.
• Ensure patients records are contemporaneous and secure.
• Introduce and embed formal governance systems including effective recruitment arrangements and systems for assessing, monitoring, and addressing risks.
• Seek and act on feedback from relevant persons for the purposes of continually evaluating and improving the quality of service provision.
• Formalise the leadership structure and ensure there is appropriate leadership capacity to deliver all improvements required, including addressing staff issues such as interpersonal issues and ensuring adequate staff cover.

• Implement robust processes for identifying and accidents/ incidents.
• Take action to ensure safe and effective management of refrigerated medicines, ensure Patient Group Directions are in place to allow nurses to administer medicines in line with legislation, and obtain atropine medicine for patient’s emergency use, (recommended for practices that fit coils/for patients with an abnormally slow heart rate).
• Ensure effective arrangements for infection control and management of risks such as Legionella.
• Ensure effective, induction, supervision and appraisal arrangements for all staff in accordance with their role.
• Ensure all staff receive training in Basic Life Support (BLS), infection control, fire safety, chaperoning, and child and adult safeguarding as appropriate to their role.

The areas where the provider should make improvement are:

• Seek to improve identification of and support for patients that are carers.
• Put systems in place to ensure all clinicians are kept up to date with safety alerts and clinical best practice guidelines and introduce a system to monitor use of prescription pads.
• Implement business continuity planning to address the possibility of the plan being damaged or destroyed in the event of premises damage.
• Update the patient’s information leaflet to accurately reflect GPs sessions and make suitable arrangements to ensure patients are aware of translation services.

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, or 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