We carried out an announced comprehensive inspection at Bermondsey Spa Medical Practice on 10 July 2018. We rated the practice inadequate and they were placed into special measures. Because of the concerns found at the inspection, we served the provider with a notice to impose an urgent suspension of the regulated activity of Surgical Procedures from the location for a period of three months from 17 July 2018 to 12 October 2018 under Section 31 of the Health and Social Care Act 2008 (“the Act”).

We carried out this announced focussed follow up inspection on 1 October 2018 to check if the provider had made sufficient improvements to allow the period of suspension to end, or if further enforcement action is required. The practice was not rated on this occasion.

Following this focused inspection, we found the provider had not implemented sufficient improvements.

Our key findings were as follows:

• Infection prevention and control risks associated with the practice’s proposed minor surgery room were not addressed.
• The provider had not made suitable preparations to undertake quality improvement activities in relation to surgical procedures.

We have imposed an urgent condition that the provider must not carry out surgical procedures from its location.

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.
• Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance.

The area where the provider should make improvements are:

• To review their processes so they have assurance that equipment needed for minor surgery procedures is available and in place when procedures are carried out.
• To review their processes to ensure patient information leaflets are made available as part of their arrangements to seek consent

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as inadequate overall. (Previous rating 12 2017 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Inadequate

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Dr Shabir Bhatti (also known as Bermondsey Spa Medical Practice) on 10 July 2018 in response to concerns.

At this inspection we found:

• The practice had did not have clear systems to manage risks to patient safety; particularly in relation to infection prevention and control during surgical procedures, medicines management and dealing with medical emergencies.
• We found there were poor governance practices which meant safety systems and processes did not minimise risks relating to infection prevention and control, suitable staffing, arrangements for dealing with medical emergencies, medicines management, and acting on and learning from internal and external safety events.
• Consent was not being lawfully sought in relation to surgical procedures
• The practice did not routinely review the effectiveness and appropriateness of the care it provided.
• Patients reported that they were not able to access care when they needed it. They were not able to get through to the practice phone lines, and appointments were not available when they needed them.
• There were arrangements in place to support continuous learning and improvement for staff at all levels, but these were not consistently effective.

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

• Care and treatment of service users is provided with the consent of the relevant person
• Ensure care and treatment is provided in a safe way to patients.
• Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance.

We issued an urgent notice of suspension of the regulated activity of surgical procedures for a period of three months from 17 July 2018.

On 17 July 2018, we issued warning notices for breaches of regulations 12 (Safe care and treatment) and 17 (Good governance), and asked the provider to ensure they became compliant by 17 August 2018.

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, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to 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

Letter from the Chief Inspector of General Practice

Dr Shabir Bhatti received a comprehensive inspection on 15 October 2015. The overall rating for the practice was inadequate. The practice was placed in special measures and was found to be in breach of seven regulations. Requirement notices were set for regulations 12, 13, 15, 16, 17, 18 and 19 of the Health and Social Care Act 2008. Since the October 2015 inspection the registered provider of the practice changed from Dr Shabir Bhatti to a partnership of Dr Shabir Bhatti and Dr Bilal Bhatti.

We carried out an announced comprehensive inspection of Dr Shabir Bhatti on 3 November 2016. Significant improvements were found and the overall rating for the practice was good. However, the practice was rated as requires improvement for providing safe services. This was because the provider did not have a defibrillator available at the practice or an appropriate risk assessment to indicate how they would deal with a medical emergency that required one. We also found that procedures for checking medicines and equipment taking on home visits, identifying carers and recording multidisciplinary team meeting discussions required a review.

The full comprehensive report can be found by selecting the ‘all reports’ link for Dr Shabir Bhatti on our website at www.cqc.org.uk.

This inspection was an announced desk-based follow up inspection carried out on 25 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation 12 that we identified in our previous inspection on 3 November 2016. This report covers our findings in relation to those requirements and also where additional improvements have been made since our last inspection.

Overall the practice is rated as good. Specifically the practice was now found to be good for providing safe services.

Our key findings were as follows:

• The practice had access to an automated external defibrillator (AED) for use in medical emergencies.

• The practice had implemented formal procedures for checking equipment and medicines taken on home visits, to ensure they were safe for use and accessible.

• Minutes of multi-disciplinary meetings were kept, however they did not contain sufficient contents of the discussions or resulting action points. The practice had reviewed this after the inspection.

• The practice had implemented a new system for identifying carers which was laid out in their carers’ identification protocol. A carers' notice board had been provided in the waiting area. The practice had currently identified 70 carers which was 0.65% of the practice population.

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

The provider should:

• Ensure that minutes of multi-disciplinary meetings contain sufficient detail to capture contents of discussions and resulting action points.

• Ensure ongoing identification of carers so that the needs of carers can be met.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Following an earlier comprehensive inspection of Bermondsey Spa Medical Practice on 15 October 2015 the practice was given an overall inadequate rating. The practice was placed in special measures and was found to be in breach of seven regulations. Requirement notices were set for regulations 12, 13, 15, 16, 17, 18 and 19 of the Health and Social Care Act 2008.

Since the October 2015 inspection the registered provider of the practice changed from Dr Shabir Bhatti to a partnership of Dr Shabir Bhatti and Dr Bilal Bhatti. A registration site visit to the practice took place on 02 August 2016 and the partnership was registered with CQC on 15 September 2016.

We carried out an announced comprehensive inspection on 03 November 2016 to consider if all regulatory breaches in the previous inspections had been addressed, and to consider whether sufficient improvements had been made to bring the practice out of special measures. At this inspection we found significant improvements had been made. 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 an effective system in place for reporting and recording significant events.
• Risks to patients were generally assessed and managed, however the practice did not keep records of multidisciplinary meetings.
• 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 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.
• 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.

• The practice had good facilities and was well equipped to treat patients and meet their needs, however there was no defibrillator on the premises. The practice told us that this had been discussed in a clinical meeting and a risk assessment made which determined that a defibrillator was not needed.

• There was a clear leadership structure and staff felt supported by management. Staff told us that the level of support had increased significantly since the previous inspection.

• The practice proactively 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.

The areas where the provider must make improvements are:

• Do all that was reasonably practicable to assess, monitor, manage and mitigate risks to the health and safety of service users with regards to providing an automatic external defibrillator (AED) for use in medical emergencies.

The areas where the provider should make improvements are:

• Implement formal procedures for checking equipment and medicines taken on home visits, to ensure they are safe for use, comprehensive and accessible in a timely manner.

• Keep minutes to evidence frequency and content of multi-disciplinary meetings.

• Review how they identify carers to ensure their needs are known and can be met.

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

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shabir Bhatti (also known as Bermondsey Spa Medical Centre) on 23 January 2019.

At this inspection we followed up on breaches of regulations identified at our last comprehensive inspection on 10 July 2018. At that inspection, we rated the practice inadequate overall and in all the five key questions we ask, and they were placed into special measures. Because of the concerns found at that inspection, we served the provider with a notice to impose an urgent suspension of the regulated activity of Surgical Procedures from the location for a period of three months from 17 July 2018 to 12 October 2018 under Section 31 of the Health and Social Care Act 2008 (“the Act”). We also served warning notices for breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance), which we asked them to have become complaint with by 17 August 2018.

We carried out a focussed inspection to check whether the provider had made sufficient improvements to become compliant with regulations 12 and 17. We carried out two visits as part of that inspection. The first was unannounced and carried out on 3 September 2018, and the second was announced at short notice and carried out on 11 September 2018. Following that focused inspection, we found the provider had implemented sufficient improvements to become compliant with regulations 12 and 17. However, we found further evidence which indicated the provider was not fully compliant with regulation 18 (Staffing).

We carried out an announced focussed follow up inspection on 1 October 2018 to check if the provider had made sufficient improvements to allow the period of suspension of the Surgical Procedures regulated activity to end, or if further enforcement action was required. Following that focused inspection, we found the provider had not implemented sufficient improvements. We served the provider with a notice of decision to impose an urgent condition that the provider must not carry out surgical procedures from its location effective from 17 October 2018.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall. This practice remains in special measures.

We rated the practice as requires improvement for providing safe services because:

• The practice had clear systems and processes to keep patients safe.
• The practice had appropriate systems in place for the safe management of medicines.
• However, the practice did not consistently learn and made improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance
• The practice’s performance on quality indicators for long term conditions was in line with local and national averages. We noted that whilst the practice had relatively high exception reporting rates for several clinical areas, they were able to demonstrate that this was due to errors in their clinical records system.
• However, the practice could not demonstrate that staff had the skills, knowledge and experience to carry out their roles.

We rated the practice as requires improvement for providing caring services because:

• The practice respected patients’ privacy and dignity.
• Patients we spoke with during our inspection and those who completed comments cards, spoke favourably about the practice: that the staff treated them with respect, that they felt listened to and that they had observed improvements in the practice.
• The practice’s results for the national GP Patient Survey were below the local area and national averages for questions relating staff dealing with patients with kindness and respect, and involving them in decisions about their care.
• Whilst the practice acted in response to other patent feedback, they had not taken any action in response to their national GP Patient Survey results.
• The practice had identified a relatively low proportion of people with caring responsibilities.

We rated the practice as inadequate for providing responsive services because:

• The practice organised and delivered services to meet patients’ needs.
• Complaints were listened and responded to, and used to improve the quality of care.
• Patients told us they could not always access care and treatment in a timely way. This finding was consistent with the results of the national GP Patient Survey.
• The practice had taken some action to address feedback about difficulties accessing services. However, they could not demonstrate their actions had been effective. Patient feedback during our inspection day continued to be mixed about the accessibility of the service.

We rated the practice as inadequate

for providing well-led services because:

• The practice had made improvements since our inspection on 10 July 2018, and partly addressed the breaches we found at our previous inspections in relation to regulated activities currently provided in the practice. However, we have ongoing concerns about the sustainability of these improvements.
• There were areas, previously highlighted at past inspections, where the practice continues to underperform; particularly in relation to risk management, supporting staff and acting and responding to patient feedback.
• The practice did not always act on appropriate and accurate information.
• The practice did not involve the public, staff and external partners to sustain high quality and sustainable care.

These concerns we found in providing effective and responsive services affected all population groups so we rated all population groups as inadequate.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review their processes to ensure mandated staff training and appraisals are completed in accordance with the organisational requirements.
• Act to encourage uptake of the national screening programmes.
• Explore ways to improve cervical screening rates.
• Take steps to identify people with caring responsibilities so that they can be supported and signposted to appropriate services.
• Act to ensure appropriate arrangements are in place for infection prevention and control.
• Work with the system provider to resolve the exception reporting issue.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care