Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. The practice is rated as requires improvement for providing effective care to the population groups of People with long-term conditions and People experiencing poor mental health (including people with dementia). This resulted in the practice being rated as requires improvement for the key question of are services effective? (The previous inspection was on 27 January 2017 and 1 February 2017 when the practice was rated as Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Dr Hafiz Rehman (also known as Thornton Lodge Surgery), 60 Thornton Lodge Road, Huddersfield, HD1 3SB on 15 November 2017.

This was to check that the practice had taken action to address a number of significant shortfalls, which we had identified during our previous inspection in January and February 2017. Following that inspection, the practice was rated as inadequate overall and for providing safe, effective and well-led services. It was rated as good for providing caring and responsive services. We issued two warning notices and a requirement notice under the Health and Social Care Act 2008 and placed the practice into special measures.

At this inspection, on 15 November 2017, we found that the practice had taken action to remedy the breaches in regulations. For example, health and safety concerns had been addressed, outdated policies had been reviewed, effective clinical audits were being undertaken, deficits in staff training had been rectified and systems to ensure the safe management of vaccines had been implemented. Overall the practice is now rated as good.

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. When things went wrong, reviews and investigations were thorough and lessons learned were communicated to support improvement.
• 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. We saw that the system for sharing drug safety alerts across the practice was sufficiently monitored.
• We saw that staff treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and told us that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• The majority of patients had access to the GPs personal phone number in case of queries or emergencies, and at the time of death, the GP would facilitate early burial for religious reasons.
• The practice used visual aids in order to effectively support patients living with diabetes to modify their diets.

The areas where the provider should make improvements are:

• Continue to review and improve the care and treatment provided to people living with long-term conditions, including those living with diabetes, and for people experiencing poor mental health, including people living with dementia.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service. These improvements now need to be sustained, moving forwards.

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 the practice operated by Dr Hafiz Rehman, at Thornton Lodge Surgery on 1 December 2015. Overall the practice is rated as good.

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

• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect.
• 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 GP and that there was continuity of care, with urgent appointments available the same day.
• 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 management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the Duty of Candour.

However there were areas where the provider should make improvements:

• The practice did not have a defibrillator available, whilst it is not mandatory to provide such equipment, practices are encouraged to have equipment such as defibrillators in the event of cardiac arrest occurring on the premises.The practice should therefore undertake a formal risk assessment as to how to manage emergency situations with the equipment currently available within the practice, in addition the practice should ensure that all staff are aware of the action they should take in event of such an emergency.

• During the inspection it was noted that there was limited contact between the practice lead GP and the newly qualified regular locum.The practice should improve the support, oversight and contact provided to their locum and in particular ensure that the locum is provided with updates about the practice, management arrangements and clinical issues.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a focussed inspection of the provider on 27 January 2017. This was to follow up issues around safe care that had been identified at an earlier comprehensive inspection in December 2015. During the course of the focussed inspection we identified a number of new concerns. As a result, we returned to complete a comprehensive inspection of the practice on 1 February 2017.

Overall the practice is rated as inadequate.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, there was a very low number of incidents recorded over the previous year. When things went wrong, reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement. Staff were open and apologised to patients, however, some senior staff we spoke with were unaware of the regulation relating to duty of candour and a clear policy on this requirement had not been developed by the provider.

• Although some risks to patients were assessed, they were limited in scope. For example, there was no health and safety assessment of the premises or evidence of an electrical system check being completed within the last five years. One clinician did not have the required indemnity insurance to cover the number of sessions they undertook, and some recruitment checks had not been consistently applied.

• Whilst the practice could confirm that the lead clinician had the required training in safeguarding, mandatory training in health and safety had not been completed by all staff.

• The practice had adequate arrangements to respond to major incidents such as a power failure. However, we saw that the practice did not have oxygen available onsite for use in a medical emergency. The practice confirmed after the inspection that a supply of oxygen had now been ordered. There were no records of maintenance checks on the defibrillator kept.

• Medicines were not safely managed across the practice. This included inadequate monitoring of vaccine stocks, inadequate safeguards to the power supply for the medicines fridge, security of medicines in an unlocked fridge, expired emergency medicines and a lack of authorisation and review for administration of certain medicines that require this.

• Data showed some patient outcomes were low compared to the national average. There was no recent audit activity to drive improvements to patient outcomes.
• We observed patients being treated with compassion, dignity and respect. Results from the national GP patient survey aligned with our observations. Vulnerable patients had been identified and could receive same day access to appointments if requested.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, the system for sharing drug alerts across the practice was not sufficiently monitored. Communication with other health professionals was sometimes haphazard and led to a delay in communicating patient information. The management of test results was vulnerable to delay.
• 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. However, verbal complaints were not recorded and there was no evidence of learning from complaints being shared across the staff team.

• The practice had a number of policies and procedures to govern activity, but many of these were significantly overdue for review and/or originated from other providers and contained inaccurate information.

• Governance meetings did occur, however they were relatively infrequent. Minutes from these meetings were not sufficient to support learning and ongoing review.

The areas where the provider must make improvements are:

• Improve the processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Take action to address identified concerns with health and safety across the practice.

• Ensure that all necessary recruitment checks in regard to securing references for all staff are carried out.

• Carry out quality improvement activity, including re-audits to ensure improvements have been achieved and are sustained.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Provide staff with appropriate policies, clinical supervision and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

The areas where the provider should make improvement are:

• Review arrangements for the identification and support of carers amongst the patient population.
• Review arrangements for the monitoring of cleaning activity to be assured that standards of cleanliness are consistently maintained.
• Review the arrangements for the sharing of medicine alerts to assure themselves that information has been seen and acted upon.
• Review the arrangements for seeking written consent for circumcision services to assure themselves that they are following recommended practice.
• Review the approach taken in targeting patients for bowel and breast cancer screening to improve uptake and review areas of chronic disease management to drive improved outcomes for patients.
• Review arrangements for the management of complaints to be assured that patients are consistently advised of their right to refer their complaint to the Parliamentary and Health Ombudsman if they remain dissatisfied with the provider’s response and that effective learning is implemented across the staff team.

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