Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection on 16 February 2017, where the practice was rated as requires improvement overall. Before this the practice had been in special measures following an inspection in May 2016. The practice was taken out of special measures, but there were still areas which needed improvement. These included maintaining accurate and complete records of patient care and treatment; reviewing arrangements for identifying patients who were also carers; reviewing arrangements related to not having a defibrillator on site; and reviewing arrangements for reporting significant events to external bodies.

The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for Dr Lawson and Dr Alalade on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 October 2017 to confirm that the practice had met the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection on 16 February 2017.

Overall the practice is now rated as good.

Our key findings were as follows:

Improvements had been made and the requirement to maintain an accurate and complete record in respect of each patient including care plans had been met. Care plans were shared with the patient and other relevant health professionals. Also:

• The practice had reviewed its risk assessment related to having a defibrillator on site and had purchased one.

• The practice was more proactive in identifying carers to provide appropriate support.

• The practice was working more closely with the patient participation group and involving them in the running of the practice.

• The practice had started to use a reporting system for significant events which enabled them to report to external bodies and there was evidence on acting fully on safety alerts.

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

The provider should:

• Review arrangements for sharing information about vulnerable patients, particularly those with a mental health condition who moved to another area or who do not attend appointments.

• Continue with arrangements to identify patients who are also carers to improve numbers.

• Review the process for ensuring that blood tests have been completed and the results have been received, prior to medicines being prescribed.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 16 February 2017. Overall the practice is now rated as requires improvement.

Previously, we carried out an announced comprehensive inspection at Dr Lawson and Dr Aladade on 18 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Lawson and Dr Aladade on our website at www.cqc.org.uk.

Shortfalls identified at the inspection in May 2016 included a lack of governance processes to manage and mitigate risks to patients; a lack of opportunities for staff to provide feedback on service provision; training arrangements were not adequate to ensure staff were supported to carry out their roles. In addition care planning and improving health outcomes for patients was not consistently provided in a manner which met their needs, including those with specific religious needs.

Our key findings were as follows:

• There was an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver care and treatment.
• Data showed patient outcomes were low compared to the national average. Unverified data received from the practice showed that exception reporting was improving, but processes in place were not yet fully embedded so that the practice could demonstrate they were meeting patients’ needs and improving outcomes.

• Care plans for long term conditions were not routinely kept on patient records or shared with other health professionals.

• Data from the national GP patient survey showed patients rated the practice lower than others for some aspects of care. The practice had carried out a survey of their own to determine possible causes, as national survey results did not align with other positive patient feedback.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they could make an appointment with a named GP, 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 leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

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

Importantly, the provider must:

• Maintain securely an accurate and complete record in respect of each patient, including care plans discussed with them and noting when these have been shared with other health professionals when appropriate.

In addition the provider should:

• Review the reasons and risk assessment related to not having a defibrillator on site.

• Review arrangements for identifying patients who are also carers’ and provide appropriate support.

• Review arrangements for working with the patient participation group to promote the groups involvement with the running of the practice.

• Review arrangements for reporting significant events to external bodies and acting on safety alerts.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.

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 inspection at Dr Lawson and Dr Aladade on 24 November 2016 to monitor whether the registered provider had met the requirements of a warning notice.

Our previous inspection in May 2016 was a comprehensive inspection and we rated the practice inadequate overall. The full report is on our website. As a result of the inspection a warning notice was served. The timescale given to comply with the warning notice was 31 October 2016. The warning notice served related to regulation 17 of the Health and Social Care Act 2008: Good governance.

Areas which did not meet the regulatory requirements were:

The registered person did not have appropriate systems, processes and policies in place to manage and monitor risks to the health, safety and welfare of patients, staff and visitors to the practice:

• Systems in place to demonstrate that significant events were handled appropriately were not effective and did not show that actions had been taken to minimise risk and was monitored.

• The registered person did not have systems in place to ensure they were able to maintain an accurate and complete record in respect of each service user at all times.

• There was no consistent system in place to ensure consent forms were scanned onto computerised records.

• We found that care plans were in paper format and the practice was unable to demonstrate that these had been shared with other health professionals or the patient concerned.

• The registered provider did not proactively engage with staff or provide opportunities for staff to formally feedback on service provision or staffing numbers.

• Training arrangements did not demonstrate that all staff had the necessary skills and competencies to carry out their role.

At this inspection on 24 November 2016 we found the provider had complied with the warning notice and was now compliant with the regulation 17 as set out in the warning notice.

Our key findings were:

• Systems were in place to manage significant events appropriately. There were clear processes for reporting and acting on concerns, with details of monitoring actions. Minutes of meetings showed that these had been discussed with staff and learning points noted.

• Arrangements for record keeping had improved and the practice was able to demonstrate that a complete and accurate record was maintained for each service user.

• We found consent forms were scanned onto records in a timely manner.

• Care plans were routinely shared with the patients and relevant health care professionals.

• Staff were provided with opportunities to comment on service provision and staffing.

• The practice had implemented a comprehensive training log and training had been planned for the future.

We have not reviewed the ratings for the practice as part of this inspection. Therefore the overall rating remains inadequate.

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 Lawson and Dr Aladade on 18 May 2016. Overall the practice is rated as inadequate.

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. However, reviews and investigations were not thorough enough. Patients did not always receive an apology.
• Risks to patients were assessed and managed.
• Data showed patient outcomes were low compared to the national average. Some audits had been carried out, an audit finding was used by the practice to improve services with recent action taken for the reviewing of the prescribing protocol for antibiotics to ensure their use was necessary and effective.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
• Information about services was available and interpreters were available if needed.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review.

The areas where the provider must make improvement are:

• Ensure care and treatment is consistently provided in a manner which meets patients’ needs and preferences. Ensure improved health outcomes for patients who may be reluctant to attend the practice for personal or religious reasons.
• Ensure that information about care needs are appropriately shared with other relevant professionals.
• Arrangements for consent for procedures must be clear and recorded; and allow for an auditable trail of when consent is obtained.
• Ensure training is completed for staff safeguarding adults and that policies and procedures are current and relevant.
• Ensure governance arrangements in the practice are implemented and managed effectively to demonstrate that risks to patients are minimised; staff are provided with opportunities to formally feedback on service provision; staff have received training appropriate for their role and records demonstrate that this is planned for and given.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

Special measures will give patients 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

We spoke with four people who used the service, this included one active member of the Patient Participation Group (PPG), and with clinical and non-clinical staff.

People we spoke with were generally positive about the service they received. People told us they didn’t have any problems getting an appointment. The majority of people told us that the staff were caring, respectful and polite. Two people told us they were excellent, one person told us the nurses were very good but they did not like the approach of one GP, so no longer see them. They told us, “This was a personal choice”. People said that during consultations the staff explained issues and answered questions in a way they could understand. One person told us, “I am always listened to and involved”.

People received care that ensured their safety and welfare. People were assessed and care was provided to meet their individual needs. Diagnostic tests were carried out where required, referrals made if necessary, and, appropriately followed up.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and respond appropriately.

The provider operated a robust recruitment policy and ensured appropriate checks were carried out.

The practice monitored the quality of the service by performing audits and seeking the views of the patients by surveys and engagement in the Patient Participation Group (PPG).