Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of this practice on 20 and 28 January 2016. Overall, we rated the practice as requires improvement. There were breaches of legal requirements. In particular, we found:

• Appropriate systems and processes were not in place for assessing, monitoring and improving the quality of the care and treatment patients received.

• The provider had not taken appropriate action to make sure the staff they employed had undergone the required pre-employment checks. Also, some staff that acted as chaperones had not had a Disclosure and Barring Service check or received appropriate training.

• The provider had not taken action to make sure they were correctly registered.

After the comprehensive inspection the practice told us what they would do to address the identified breaches. We undertook this announced focussed inspection, on 16 August 2016, to check that the practice had implemented their action plan and to confirm that they now met the legal requirements. You can read the report of our last comprehensive inspection by selecting the ‘all reports’ link for Dr Mazarelo & Partners on our website at www.cqc.org.uk.

Our key findings were as follows:

The provider had complied with the requirement notices we issued following our last inspection visit. In particular, we found:

• The arrangements for dealing with and recording significant events had been improved.

• Staff carrying out chaperone duties had received appropriate training and had undergone a Disclosure and Barring Service (DBS) check.

• Most staff had received the training they needed to carry out their roles and responsibilities safely and effectively.

• The provider had also taken steps to make sure they were correctly registered.

However, there were also areas where the provider needs to make improvements. The provider should:

• Put in place suitable arrangements for monitoring the action taken in response to safety alerts.

• Arrange for staff to complete their outstanding training.

• Review the standard letter issued in response to complaints received to include details of the Parliamentary and Health Service Ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Dr Mazarelo & Partners (also known as Concord Medical Practice) is situated in Washington and provides primary medical care services to patients living in and around the Washington area. The practice provides services to 5259 patients.  

The service is registered with CQC to provide the regulated activities of; Diagnostic and screening procedures; Treatment of disease, disorder and injury; Surgical procedures and Maternity and midwifery services. 

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.  

At this inspection we found there is a lack of clear leadership and vision within the practice. Governance arrangements are unclear.  Although staff told us about actions they take to improve the service, there is a lack of a documented evidence to support this.

We found that practice is responsive in its approach to quality, rather than proactively planning for improvements. 

Patients who use the service are kept safe and protected from avoidable harm, however the practice does not have a robust approach to investigations and there isn’t a system in place which will enable the practice to identify trends in incidents, safety issues, performance issues, and to record learning.  The provider is in breach of Regulation 10 Assessing and monitoring the quality of service provision.

The building is well-maintained and clean.  

All the patients we spoke with are very positive about the care and treatment they receive.  The CQC comment cards and results of patient surveys that show that patients are consistently pleased with the service they receive.

There is good collaborative working between the provider and other health and social care agencies which ensures patients receive the best outcomes.  Clinical decisions follow best practice guidelines. 

The practice regularly meets with the local CCG to discuss service performance and improvement issues.

The majority of patients registered with the practice are of working age. There are approximately 200 patients registered with the practice over the age of 65. Patients with long term conditions are reviewed at least once a year. The practice told us they have four patients registered with a learning disability and they all have a health action plan in place and annual reviews.  The practice are aware of patients in vulnerable circumstances and actively ensure these patients receive regular reviews, including annual health checks.  The practice maintains a register of patients who experience mental health problems and they have regular reviews.  The needs of these population groups are identified by the practice and systems are in place to improve their access to care.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mazerelo & Partners on 20 and 28 January 2016. Overall the practice is rated as requires improvement.

We had previously carried out an inspection of the practice on 1 September 2014 when a breach of legal requirements was found;

• Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service provision (which corresponds to Regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014 Good governance).

After the inspection on 1 September 2014 the practice wrote to us to say what they would do to meet the legal requirements above, as set out in the Health and Social Care Act (HSCA) 2008.

We undertook this comprehensive inspection to check that they had followed their plan and to confirm that they now met legal requirements.

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

• The practice had addressed some of the issues identified during the previous inspection.
• Risks to patients, such as health and safety, were assessed and well managed.
• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses however we had concerns about recording, investigation and outcome of significant events and complaints in the practice.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• The practice could demonstrate they had an effective system in place for clinical audit and they used audits successfully to improve quality.
• Staff had received training appropriate to their roles. However it was difficult to assess if they had all received the training appropriate to their role.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice sought feedback from patients, which they acted on.
• There was a clear leadership structure in place and staff felt supported by management.
• There was a lack of good governance in the practice and some concerns we identified during the inspection reflected this.

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

Importantly, the provider must:

• Ensure that there is an effective system for the recording, investigation and outcome of significant events.

• Ensure records in relation to the management of the regulated activities are effectively maintained, for example, documentation in relation to the recording, investigation and outcome of complaints, training and recruitment in the practice. In addition ensure the registration of the practice is correct with CQC.

• Ensure to only use staff who have been trained and DBS checked or risk assessed as safe, to carry out chaperoning duties.

In addition the provider should:

• Consider infection control training for the infection control lead nurse.

• Clarify with the landlords of the health centre the cleanliness of the patient toilets.

• Follow their recruitment policy, for example maintain interview notes, keep a documented copy of references and be clear on the process for DBS checks.

• Keep a record of mandatory training required for each job role within the practice and ensure staff receive this and appropriate regular updates.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice