We carried out an announced comprehensive inspection at Church Lane Khan on 16 January 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 25 April 2018. You can read the report from our last inspection on by selecting the ‘all reports’ link for Church Lane Khan on our website at www.cqc.org.uk.

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, effective and well-led services because:

• The practice could not demonstrate that they had fully improved their recruitment and induction processes since our last inspection.
• In areas, governance arrangements were ineffective and the practice did always not have clear and effective processes for managing risks and issues.
• The practice did not always act on appropriate and accurate information. The practice did not demonstrate good governance with regards to their strategy and across specific coding issues where risks and areas for improvement had been identified.
• Patient satisfaction was below average in areas such as for care and treatment provided and for access. Although we saw that some steps had been taken to improve, the evidence provided did not demonstrate that satisfaction rates had fully improved across all areas.
• We noted in other areas that improvements had been made since our last inspection, this was reflected across sepsis awareness, child immunisation uptake, infection control and for the management of safety alerts and emergency medicines.
• Discussions with staff highlighted a significant improvement in morale at the practice.

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

The areas where the provider must make improvements are:

• 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:

• Continue to identify carers to offer them support where needed
• Continue to explore ways of improving uptake rates for cancer screening
• Continue to explore ways of engaging with patients and improving satisfaction rates
• Formally assess the need for a hearing loop to ensure that reasonable adjustments are made for patients where needed

This service was placed in special measures in July 2018. Insufficient improvements have been made such that there remains a rating of inadequate for providing safe, effective and well led services. Therefore we are taking 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 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

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

This practice is rated as Inadequate overall. (Previous inspection February 2015 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Church Lane - Khan also known as The Surgery on 25 April 2018 as part of our inspection programme.

At this inspection we found:

• That there were areas where the arrangements for identifying, recording, managing and mitigating risks were not effective.
• A system to alert practice staff when individual patients who were subject to safeguarding measures had not been established, although there were systems for staff to report safeguard concerns. Following our inspection, the practice provided evidence to assure us that a system was in place to capture safeguarding concerns on patient records.
• The practice sought to deliver care and treatment according to evidence- based guidelines. However, the practice was unable to demonstrate this in particular we found poor understanding and use of care plans and palliative care multi-disciplinary meeting templates were not completed to their entirety.
• Staff demonstrated an awareness of the practice high exception reporting rates and, although they were operating a call and recall system for patients who required a review of their condition and treatment, we did not find evidence that a comprehensive plan was in place to address this issue.
• Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the July 2017 national GP patient survey showed that the practice scored either above or comparable to local and national averages in most areas. Completed Care Quality Commission (CQC) comment cards were also positive about the services provided.
• Completed CQC comment cards reported that patients found the appointment system easy to use and reported that they were able to access care when they needed it. However, there were some comments on NHS choices that were less positive about access. Practice staff were aware of the issues and were taking some action to improve access.
• The practice governance arrangements were not effective and lacked the necessary clinical leadership or managerial oversight to ensure a systematic approach to sustain the quality of patient care and service delivery. There were areas where responsibilities had not been clearly defined and oversight of some processes was not effective. For example, the practice did not have clear oversight of safety alerts and the monitoring of actions to ensure compliance with safety recommendations.
• Although the practice aimed for a culture of high-quality sustainable care, there were a number of areas where staff felt unsupported in their role and felt when internal concerns were raised these were not acted on.

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:

• Continue to encourage the uptake of childhood immunisations and national programmes such as cervical and breast cancer screening.
• Carry out a risk assessment covering the choice and availability of medicines and equipment which may be needed in the case of a medical emergency
• Review the arrangements for tracking blank prescriptions through the practice in line with national guidance.
• Continue recalling patients and cleansing clinical records to reduce the practice exception reporting rates.
• Use appropriate care planning tools for patients identified as being frail to evidence a planned approach to patients care needs.
• Continue exploring and establishing effective methods to identify carers in order to provide further support where needed.
• Continue exploring and following actions to improve patient satisfaction in areas such as access.
• Continue reviewing non-clinical staffing levels to ensure appropriate cover during periods of low staffing levels.

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.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection at Dr Khan, Church Lane practice on 4 February 2015.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because practice staff were caring and motivated.

Our key findings were as follows:

• We found evidence that practice staff worked together to make on-going improvements for the benefit of patients.

• We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the standards of care they received.

• The practice was visibly clean and tidy. Annual in depth audits were carried out and resultant actions taken to protect patients from unnecessary infections when they visited the practice.

• The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

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

In addition the provider should:

• Record that verbal consent has been given prior to intimate examinations of patients and fully record the annual health checks carried out for patients with a learning disability.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice