This practice is rated as Good overall. (Previous rating December 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr Hazem Lloyd (Cedar House Surgery) on 19 June 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to follow up on previous identified breaches from the inspection conducted on 5 December 2017. After the inspection in December 2017 the practice was rated requires improvement overall. We issued warning notices to the provider for beaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance), we also issued the provider with a requirement notice in relation to Regulation 18 (staffing). The inspection on the 19th June 2018 was also to check whether the provider was 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. Dr Hazem Lloyd is now rated as good overall.

At this inspection we found:

• Breaches of regulations identified at the inspection conducted in December 2017 relating to safety, staffing and leadership had all been addressed.
• 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. Safety alerts were acted on, however not effectively recorded.
• 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.
• Some information required when recruiting staff had not been retained.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. A new patient participation group was being formed.

The areas where the provider should make improvements are:

• Record all safety alerts and action taken in response to them.
• Include medical declarations in recruitment information held.
• Complete recommendations from last infection control audit relating to replacement furniture and wall mounted soap dispensers.
• Appoint and train additional fire marshals.
• Consolidate the locum GP induction pack.
• Review and update the practice controlled drugs policy.
• Document protocols for monitoring high risk medicines.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (At the previous inspection undertaken in June 2016 the practice received a rating of Good overall, with a rating of requires improvement for being safe. A desktop review in October 2016 rated safe as Good.)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

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 comprehensive inspection at Dr Hazem Lloyd, Cedar House on 5 December 2017. This inspection was carried out 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 was 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.

At this inspection we found:

• Patients told us in the 46 returned comments cards that the GPs, reception and administration team were kind and caring. Patients said they could always get an appointment and believed they received good care and treatment.

• Recruitment checks were not undertaken for locum GPs that were used occasionally at the practice.

• Risk assessments for fire safety, infection control and Legionella were in place. General work place risk assessments were not adequate. General maintenance certificates such as a gas safety, electrical safety and portable appliance testing (PAT) were not available at the time of our inspection. However, the practice took action following our inspection visit and supplied copies of the gas maintenance certificate the week following the inspection, and confirmed PAT testing had been completed.

• The GP and nurses we spoke with knew how to identify and manage patients with severe infections. However, practice specific clinical pathways, procedures and protocols for care and treatment were not available, including one for responding to medical emergencies.

• The lack of defibrillator and protocol to follow in the event of a medical emergency potentially increased the risks to patients for not receiving safe effective care quickly.

• A system to routinely review the effectiveness and appropriateness of the care the practice provided was not well established for example a programme of clinical audit and re-audit and frailty assessments of older people were not in place.

• Nurses stated the GP was supportive. However, formal systems to support the nursing team were not established. For example, both nurses had not had an appraisal, did not attend staff meetings or clinical meetings, and a recorded process to audit decision making of the advanced nurse practitioner was not implemented.

• There was limited awareness of the accessible information standard; however, the practice confirmed they would implement this.

• A recorded strategy or business development plan to support the practice in meeting future challenges and priorities was not available. Governance arrangements to monitor and review the service provided were not supported by clear objectives and actions plans. This had resulted in gaps in service delivery and performance.

• The practice did not have systems in place to engage with patients. The practice had not undertaken any form of consultation with patients and did not have a patient participation or reference group. This compromised the practice’s ability to evaluate and improve the service it provided.

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

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

Please refer to the requirement notice section at the end of the report for more detail.

The areas where the provider should make improvements are:

• The practice should keep copies of training certificates such as safeguarding for all staff including locum staff.

• The practice should establish a log to capture patients’ feedback, both positive and negative and use this feedback to support the governance of the practice.

• The practice should prioritise the security of the staff reception area and the consultation rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr Hazem Lloyd, Cedar House for areas identified as requiring improvement within the key question safe.

We found the practice to be good in providing safe services. Overall, the practice is rated as good.

The practice was inspected on 8 June 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key question safe, the systems in place for assessing, monitoring and mitigating risks to patients were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 12 Safe care and treatment HSCA (Regulated Activities) Regulations 2014.

At the inspection in June 2016 we found that systems for assessing, monitoring, recording and mitigating risks to patients were not comprehensively undertaken in relation to:

• The lack of an automated external defibrillator (AED) within the practice.

• Staff undertaking the role of chaperone without a Disclosure and Barring Service (DBS) check in place (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

• Lone working.

• Legionella (Legionella is a term for a particular bacterium that can contaminate water systems in buildings).

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 12, Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 Hazem Lloyd, Cedar House on 8 and 10 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Risks to patients were not always fully assessed; for example the practice did not have a risk assessment in place to mitigate the risk of not having an automatic defibrillator and Disclosure and Barring Service checks (DBS) were not available for staff who carried out chaperone duties.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained so they had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patients were complimentary about the staff at the practice.
• Information about services and how to complain was available and easy to understand. The practice had only received one complaint in the last 12 months but took action to investigate and respond.
• Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
• The practice had the facilities and was well equipped to treat patients and meet their needs.
• Staff felt supported by management and demonstrated a clear understanding of the leadership structure.
• A patient participation group was not established and proactive engagement seeking feedback from patients was not undertaken.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Implement systems for assessing, monitoring and mitigating risks to patients for example in relation to the lack of a defibrillator, staff undertaking the role of chaperone without a Disclosure and Barring Service check (DBS) in place, lone working and Legionella.

The provider should:

• Develop and strengthen governance arrangements by clarifying the vision for the practice and ensuring all informal audit and checks carried out are recorded.
• Record the expiry dates of immunisations and vaccines to ensure a safe stock of in date medicine is always available.
• Establish a programme of regular clinical audit and re-audit.
• Ensure team meeting minutes are easily accessible to all staff.
• Review the access and availability of clinical polices and including responding to medical emergencies.

Actively promote and facilitate a patient participation group to provide feedback about the service provided by the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We last inspected Dr Hazem Lloyd on the 16th January 2014 and made compliance actions because we had concerns that the provider had limited arrangements in place to deal with foreseeable emergencies, and the provider did not operate an effective recruitment process.

During our inspection on the 6th May 2014 the provider was able to provide us with evidence which demonstrated they had effective recruitment processes in place and systems to ensure they were able to effectively manage foreseeable emergencies.

We did not speak to people who used the service during this inspection.

Consulting and treatment rooms were comfortable and private in this small surgery. We spoke with the doctor and all four staff working on the day of the inspection. We also spoke with five patients.

All patients we spoke with told us they considered that they were respected, properly consulted and involved in making decisions in consultation with their doctor. Patients said that they were treated well by the whole team.

Patients told us how much they liked the personalised service they received by being registered with a "one GP practice". One patient said: "He knows everything about me and so I don't need to repeat myself and go on about my history. He knows what I need and he takes the time to explain things to me. He gives me enough time, good explanations about what is going on and I never feel rushed". We asked people to tell us about their experience of being with a single GP practice. One patient said: “I think the doctor is able to get to know you, it’s more personal - I trust the guy, I have no issues here at all. The girls in reception are all great. They really help you".

Systems were in place to protect adults and children from the risk of abuse.

Recruitment and employment checks needed to be more comprehensive.

The premises were of a good standard, but there was no emergency oxygen on site. Also there was no mercury spillage kit available, but mercury containing equipment was available for staff to use.