Letter from the Chief Inspector of General Practice

This inspection of Dr A Bansal practice was carried out on 21 February 2017 following a period of special measures and was to check improvements had been made since our last inspection on 24 May 2016. Following our May 2016 inspection the practice was rated as inadequate overall. Specifically they were rated as requires improvement for caring and responsive, and inadequate for safe, effective and well-led. The practice was placed in special measures for a period of six months. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Dr A Bansal Practice on our website at www.cqc.org.uk.

As a result of our findings at this inspection we took regulatory action against the provider and issued them with a warning notice and requirement notices for improvement.

Following the inspection on 24 May 2016 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the breaches of regulations.

At this inspection we found that the majority of the improvements had been made and progress had been made across all areas of concern. Overall the practice is now rated as good.

Our key findings were as follows:

• Significant events were fully investigated, patients received support, honest explanations and apologies. The learning was shared with appropriate staff.

• There was a clear recruitment process in place for permanent and locum staff.

• There were systems in place to ensure safe medicines management. Patients prescribed high risk medicines received appropriate review and action had been taken to reduce the levels of anti-bacterial prescribing.

• There was a system in place to deal with any medicines alerts.

• Prescription paper was monitored and stored securely.

• Infection control audits were completed and action taken to resolve any issues. Legionella monitoring and safety measures were completed on a regular basis.

• Policies and procedures were up to date and staff were aware of where to find them and their contents.

• A range of audits and re audits had been completed to improve the quality of service provision.

• Clinical outcomes were still lower than Clinical Commissioning Group (CCG) and national averages for patients with a long term condition and those experiencing poor mental health. There were plans in place to further improve outcomes for those patients with a long term condition and outcomes for this group had improved. However further work was required to improve outcomes for patients experiencing poor mental health.

• The practice had a system for identifying and supporting the carers on their register.

• The complaints policy was clearly visible to patients. Complaints were fully investigated and there was a clear audit trail of actions taken by the practice.

• There was a process in place to gather and act on patient feedback.

• Staff had worked as a team and with the CCG to act on the feedback from the previous inspection.

• The overall governance and leadership arrangements had been reviewed and strengthened.

However, there was one area of practice where the provider needed to make improvements.

The provider should:

• Improve outcomes for those patients experiencing poor mental health and those with long term conditions.

  I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the 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 comprehensive inspection at Dr A Bansal Practice on 24 May 2016. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, although reviews and investigations were completed there was limited evidence of learning and some investigations were not as thorough as they could be.
• Although some risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken.
• There were no systems in place for some areas of medicines management. For example, patients prescribed high risk medicines or those requiring regular monitoring were not being monitored. Blank prescription forms and pads were not securely stored and there were no systems in place to monitor their use.
• The practice had high rates of anti-bacterial prescribing.
• There was a system in place for staff to be aware of patient and medicines related safety alerts, however no action was taken once the alerts had been received.
• Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Urgent appointments were available the same day.
• The practice had good facilities and was equipped to treat patients and meet their needs.
• There was no information displayed telling patients how to complain. The complaints investigations were not fully documented and for some did not fully address the extent of the complaint. Learning from complaints was minimal.
• Staff felt supported by one of the partners and able to raise concerns .
• Data showed most patient outcomes were low compared to the national average. Although some clinical audits had been carried out in previous years there were no clinical audits completed in the last 12 months and no other quality improvement systems in place.
• The practice was aware of performance related data but there was no evidence that this information had been used to improve patient outcomes.
• The practice had a number of policies and procedures to govern activity which were in the process of being reviewed and updated but staff were not aware of them or their content.
• The governance systems in place were not sufficient to ensure safe, effective, responsive care and treatment.

The areas where the provider must make improvements are:

• Introduce robust governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Carry out quality improvement activities for example, clinical audits including re-audits to ensure improvements have been achieved.
• Introduce robust medicines management systems for: the review of patients prescribed high risk medicines and those requiring monitoring; the security and monitoring of prescription paper and pads; dealing with alerts relating to medicines.
• Take action to address high levels of anti bacterial prescribing.
• Take action to address identified concerns with infection prevention and control practice.
• Investigate safety incidents thoroughly and ensure that patients affected receive reasonable support and a verbal and written apology and that learning is disseminated appropriately.
• Make information relating to complaints easily accessible. Investigate complaints thoroughly and ensure there is a clear audit trail of the investigation.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure that a legionella risk assessment takes place and complete any actions identified from the assessment in a timely manner.

In addition the provider should:

• Ensure that practice policies are up to date and that staff are aware of their content and that they are readily available.
• Improve the performance of the practice in relation to the clinical outcomes of patients measured by the Quality and Outcomes Framework.
• Ensure that there is a plan in place to respond to and act on patient feedback.
• Improve the system for the identification of carers and offer them appropriate support and guidance.

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

We conducted a follow up inspection of the service. This was to check that the provider had addressed previous areas of non-compliance identified in respect of infection prevention control and the assessing and monitoring of the service. 

During our earlier inspection we found that no infection prevention control audit had been conducted to identify potential risks to patients, a medical device for examining patients ears was dirty and no cleaning records had been completed by the contracted cleaning company to demonstrate what had been cleaned and when. We also found that the practice had not identified learning from previous serious incidents or reviewed actions given to staff to ensure tasks were progressed in a timely and appropriate manner.

On our return we found the provider had conducted an infection control audit and supporting action plan. Outstanding actions were being progressed by the infection prevention control lead nurse and closely monitored by the practice manager. Consultation and treatment rooms were bright, clean and tidy and systems had been implemented to ensure staff were aware of and adhered to the cleaning requirements relating to their environment and equipment.   

We found that people could access translation and advocacy services. Where people lacked capacity to consent, the provider acted in accordance with legal requirements. We found staff had appropriate equipment in place to deal with emergencies, which they reasonably expected to arise.

The nursing team received regular clinical supervision and all nine staff members personnel files reviewed contained an appraisal and training and development plan. Staff told us they had received training and were supported in their professional development.

We found no infection prevention control audit had been conducted to identify risks to people using the service. We also found dirty medical equipment used to examine people’s ears. The practice conducted regular practice and clinical meetings. However, we found the practice was not reflecting on learning from significant incidents to improve future practice.

We found people did not have access to translation and advocacy services to assist them to understand and make informed decisions. People were assessed and their care and welfare was planned and delivered to meet their needs. However, the practice did not have sufficient arrangements in place to deal with foreseeable emergencies.

The practice was tidy and cleaner than when we previously inspected in Novemebr 2013. However, we found the provider still did not have effective systems in place to reduce the risk and spread of infection.

The provider had worked with Essex Fire and Rescue Service to address the risks identified in our earlier inspection. This involved the installation of a fire alarm, emergency lighting and staff training in evacuation procedures and the use of extinguishers. Staff had received an annual appraisal and training in safeguarding but still were not receiving regular and appropriate supervision in their role.

The provider was not conducting regular assessments or monitoring of the service other than for surgical procedures. We found stock checks were incomplete and failed to identify medicines that had expired. There were also no arrangements in place to regularly consult with patients.

People we spoke to told us, it can be "Difficult to get an appointment over the phone" and people are "Not always able to see the same sex doctor." However, people also told us “The nursing care is very good, excellent."

We found that there were no procedures in place to obtain patient consent other than in relation to surgical procedures. Staff did not have an understanding of the Mental Capacity Act or parental responsibility and were unable to show how they acted in accordance with legal requirements. We found that there was no management oversight of initial health assessments to ensure the needs of the person were accurately assessed. There were also no procedures in place for dealing with emergencies which are reasonably expected to arise.

We found the provider did not have effective systems in place to reduce the risk and spread of infection. There was no infection prevention control lead and the cleaning schedules were incomplete.

The provider had no records relating to the training or development of their staff, who had not received an appraisal for two years. The practice manager told us that they did not have a formal system, policy or procedure in place to evaluate and improve the quality of the service. They confirmed actions identified by Essex County Fire and Rescue Service and an outside agency remained outstanding.

We spoke with people who told us: "We have been here fifteen years, we moved out of the area but I asked to stay as I like it here" and "Never had any problems always listen to you...very thorough." People were happy with their care although some voiced concerns regarding the appointments system saying "We've been here five years. It's not brilliant but it's ok. Difficult to make an appointment especially if you work, the appointment times are difficult."