Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr King Stott and Pankhurst (Emperor’s Gate Surgery) on 30 September 2015. Overall the practice is rated as good.

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.

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. Information about safety was recorded and monitored, appropriately. However, there were no consistent records to demonstrate that learning points from significant events were documented and shared with staff.
• Risks to patients were assessed and well managed including management of medicines, infection control and health and safety procedures.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said staff were helpful, caring, professional, and friendly and that they were involved in decisions about their care and treatment.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available the same day following telephone triage consultation assessment with the duty doctor.
• 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.

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

The provider should;

• Ensure that a legionella risk assessment is undertaken.
• Ensure that learning from all significant events is clearly documented and shared with practice staff.
• Ensure all staff have received up to date training in safeguarding vulnerable adults.
• Ensure that sharps containing cytostatic or cytotoxic medicines are disposed of in line with national guidance.
• Ensure there is a system in place for monitoring distribution of prescription pads.
• Ensure training records include evidence that staff have completed online e-learning training modules.
• Ensure that there is an emergency alarm available in the patient toilet.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Dr King Stott and Pankhurst is also known as Emperors Gate Surgery. It is a teaching GP practice that provides GP primary care services to people living in the south of the borough of Kensington and Chelsea. It currently has just over 5000 patients registered. There are three partners at the practice who have up to four registrars working with them at any one time. They are registered to provide diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

All patients we spoke with were very complimentary about the service. There was a patient participation group (PPG) that met four times a year. We saw changes were made as a result of feedback.

The practice was responsive to patients needs. They worked well with other services to keep patients in the community and prevent hospital admissions. They had access to specialist advice such as psychiatrists and physiotherapists and met regularly with district nurses, health visitors and the palliative care teams. An Age UK support worker attended the practice to provide support and act as an advocate for older patients.

The practice was providing effective care. They used a range of resources to provide evidence based assessments and treatment, such as National Institutes for Health and Care Excellence (NICE) guidelines and clinical knowledge summaries (CKS) which provides information about best practice.

The practice was caring, however some improvements were needed. CQC feedback cards completed were extremely positive about the practice. Although most patients were happy with the service they received some patients had expressed concerns about lack of appointments outside working hours.

There were arrangements in place to ensure patients were safe, however some improvements were needed. Where potential risks were identified, risk management plans were drafted with clear actions to be taken to minimise or alleviate the risk. However, we found the practice did not have arrangements in place to risk assess non-clinical staff for whom they did not carry out criminal record checks with the Disclosure and Barring Service (DBS). Further, some staff had not attended adult safeguarding training and as such could not clearly identify signs of abuse.

The practice was well led, however some improvements were needed. Three partners and a practice manager formed the leadership team. All had clear areas of responsibility. However, there were no formal processes in place to gather feedback from staff.

We reviewed the information available to us about Dr King Stott and Pankhurst on 24 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.