We carried out an announced comprehensive inspection at The Lordship Lane Surgery on 12 September 2017. The overall rating for the practice was good but requires improvement for the key question: Are services safe? The full comprehensive report from the 12 September 2017 inspection can be found by selecting the ‘all reports’ link for The Lordship Lane Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 12 March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 September 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good but is still rated as requires improvement for key question: are services safe?

Our key findings were as follows:

• A general health and safety risk assessment was provided dated June 2017 but again this was lacked sufficient detail and did not address all areas of risk.
• The practice had up to date portable appliance testing.
• The fire alarms were now being tested on a weekly basis.
• The practice’s policy for monitoring uncollected prescriptions was not clear.
• The practice had not purchased an additional thermometer for their vaccine fridge and there was no evidence that the fridge thermometer was being calibrated on a monthly basis. However we were provided with evidence that the fridge temperature was being monitored daily.
• The practice had a register in place of deceased patients.
• Multidisciplinary team meetings were being held on a monthly basis.

However, there was also an area of practice where the provider needs to make improvements.

The provider Must

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

• Adhere to Public Health England’s protocols on storage of vaccines.

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 Lordship Lane Surgery (then named Dr SAKM Doha) on 23 January 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for The Lordship Lane Surgery on our website at www.cqc.org.uk.

This inspection was undertaken five months following the publication of the report of the inspection in January 2017, and was an announced comprehensive inspection on 12 September 2017. Overall the practice has improved and is now rated as good overall.

Our key findings were as follows:

• The systems and processes to address risks to patients were not as comprehensive as they needed to be. For example, the fire log indicated the fire alarms were usually tested on a monthly basis, but we saw that if the designated fire marshal was absent when the test was due, no-one else undertook it. There was a health and safety risk assessment which had been completed in June 2017. It was minimal and did not adequately review all potential areas of risk.
• The security of medicines and blank prescriptions had been improved.
• We saw staff were recording the temperature of the vaccine refrigerator each day the practice was open; however, there was only one thermometer rather than the two recommended as good practice. The vaccines we checked were all in date.
• Although the practice had a policy of checking uncollected prescriptions every three months, we found a number waiting to be collected that were older than this.
• Patients prescribed high risk medicines received regular monitoring.
• The premises were clean and a comprehensive infection prevention and control (IPC) audit had been carried out by the local clinical commissioning IPC lead. Staff at the practice had begun to take action to rectify areas identified for improvement.
• There had been a number of clinical audits undertaken in the last two years, including two completed audits where the improvements made were implemented and monitored.
• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes overall were comparable to the Clinical Commissioning Group (CCG) and national average.
• Staff had access to guidelines from NICE and told us they used this information to deliver care and treatment that met patients’ needs. Clinical staff were aware of recently issued guidelines.
• Meetings took place with other health care professionals on a monthly basis; however, we found that most of the multi-disciplinary meetings were not minuted, albeit the GP in attendance updated patient notes where appropriate.
• The practice maintained a palliative care register and held regular multi-disciplinary meetings with, for example, the palliative care consultant and the health visitors. We noted the practice did not maintain a register of patient deaths.
• Staff had the skills, knowledge, support and experience to deliver effective care and treatment.
• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
• The practice had identified 101 patients as carers (just over 2% of the practice list).
• The Patient Participation Group felt that the practice listened to what they had to say, and tried to act upon suggestions.
• All but one of the 46 patient Care Quality Commission comment cards we received were positive about the service experienced. Data from the national GP patient survey showed the practice was comparable to others for most aspects of care.
• In the week preceding this inspection the practice had employed a locum female GP, with a view to them becoming a permanent salaried GP. Patient feedback had been very positive.
• A complaint leaflet was available and since the last inspection the practice has set up a designated complaints information notice board in the reception area.
• Staff told us there was an open culture within the practice and they had the opportunity to raise any issues at team meetings and felt confident and supported in doing so.

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

Importantly, the provider must:

• Strengthen arrangements for identifying, recording and managing risks, issues and implementing mitigating actions, including an appropriate health and safety risk assessment, accurate electrical testing records and regular fire alarm tests.
• Review the process for dealing with uncollected repeat prescriptions so that they are dealt with in a timely manner.

In addition the provider should:

• Consider acquiring an additional thermometer for the vaccine fridge.
• Consider implementing a register of patients who have died.
• Make arrangements to minute multi-disciplinary meetings.

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 Lordship Lane Surgery (then named Dr SAKM Doha) on 19 May 2016. The overall rating for the practice was requires improvement, with a rating of inadequate for providing safe care. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for The Lordship Lane Surgery on our website at www.cqc.org.uk.

This inspection was undertaken six months following the publication of the report of the inspection in May 2016, and was an announced comprehensive inspection on 23 January 2017. Overall the practice remains rated as requires improvement.

Our key findings were as follows:

• Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. The practice did not have a health and safety risk assessment, for example.

• The security of some medicines and blank prescriptions needed to be improved.

• Not all patients prescribed high risk medicines had received regular monitoring.

• The premises were clean however there were several areas where infection prevention and control processes required improvement.

• There had been a number of clinical audits undertaken in the last two years; however, with the exception of the CCG led prescribing audit, none of these were completed audits where the improvements made were implemented and monitored.

• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes overall were comparative to the Clinical Commissioning Group (CCG) and national average. However, the practice was an outlier for two QOF clinical indicators relating to atrial fibrillation and cervical screening.

• Staff had access to guidelines from NICE and told us they used this information to deliver care and treatment that met patients’ needs. The practice did not, however, have systems in place to monitor that these guidelines were followed through risk assessments, audits and random sample checks of patient records.

• In most areas staff had the skills, knowledge, support and experience to deliver effective care and treatment. Not all staff had undergone appropriate training or received an annual appraisal.

• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• The practice had identified just 15 patients as carers (less than half a percent of the practice list).

• The Patient Participation Group felt that the practice listened to what they had to say, and tried to act upon suggestions but did not share information, such as complaints and the learning taken from them.

• All of the 31 patient Care Quality Commission comment cards we received were positive about the service experienced. Data from the national GP patient survey showed the practice was comparable to others for most aspects of care.

• The practice had not considered how the lack of a female GP may have affected patients; or reviewed whether or not patients’ needs were being met by being referred elsewhere.

• The practice had a complaints leaflet but this was not on display and had to be specifically requested. The practice maintained a complaints log which detailed the learning taken but we found limited evidence to show this had been discussed with staff.

• Staff told us there was an open culture within the practice and they had the opportunity to raise any issues at team meetings and felt confident and supported in doing so.

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

Importantly, the provider must:

• Ensure patients who are prescribed high risk medicines are appropriately monitored.

• Improve the security of medicines and blank prescription pads.

• Improve patient outcomes by implementing a clinical quality improvement programme and continue to monitor performance against the Quality and Outcomes Framework and clinical audit.

• Strengthen arrangements to prevent and control the spread of infections.

• Strengthen arrangements for identifying, recording and managing risks, issues and implementing mitigating actions, including a health and safety risk assessment.

• Ensure that staff have access to appropriate training including, for example, cervical screening refresher training; and receive annual apprisals.

In addition the provider should:

• Review how patients with caring responsibilities are identified to ensure information, advice and support is made available to them.

• Introduce systems to ensure all clinicians are kept up to date with national guidance and safety alerts.

• Consider how to ensure patients have access to practice information in the reception area, including the practice leaflet and the complaints procedure, and ensure that complaints are handled in line with the policy and shared with staff.

• Record the action taken when the vaccine refrigerator temperature exceeds the maximum temperature.

• Review how the needs of patients who wish to see a female GP are being met.

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 SAKM Doha's Practice on 19 May 2016. Overall the practice is rated as Requires Improvement.

We found three breaches of legal requirements. As a result, we issued a warning notice in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Safe care and treatment.

We also issued two requirement notices in relation to:

• Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Safeguarding service users from abuse and improper treatment.

• Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Fit and proper persons employed.

Details of the breaches can be found at the end of the report.

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

• Medicines management was not robust. We found out of date vaccines and other medicines. We found some out of date single use equipment. Vaccine fridge temperatures were not always being checked and recorded daily. Patient Group Directions were not in place in accordance with legislation.
• The practice did not have adequate arrangements in place to respond to emergencies and major incidents. There was no oxygen on site. The practice did not have a defibrillator and had not carried out an assessment of the risks to patients associated with this decision. There was a minimal amount of emergency medicines.
• The premises were clean, however there were several areas where the risk of cross-infection had not been addressed including the storing of patient samples in the vaccine fridge and overfilled sharps bins.
• Not all GPs had undergone level 3 safeguarding training. The practice nurse had undergone training but the practice was unable to confirm at what level. Staff demonstrated an understanding of safeguarding and child protection but not all were aware how to report concerns to external authorities.
• Risks to patients were not always assessed, for example those relating to recruitment.
• Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, we saw limited evidence that audits were driving improvements to patient outcomes.

• We found that the system used to determine which patients were given an ‘on the day’ appointment placed patients at risk, as it was dependent on the degree of information given to the receptionists and their written interpretation of it.

• The majority of feedback from the national patient survey was below the Clinical Commissioning Group (CCG) and England average.

• Information about services was available but was not displayed and had to be requested.

• The practice had a number of policies and procedures to govern activity, but staff said sometimes these were not accessible. Some were missing, such as safeguarding and chaperone policies.

The areas where the provider must make improvements are:

• Improve medicines management to include regular checks of use by dates; monitoring of vaccine refrigerator temperatures, maintenance of appropriate PGDs and safe storage of medicines.

• Regularly check single use equipment and discard any that is out of date.

• Take action to address identified concerns with infection prevention and control practice including sharps management, implementation of cleaning records, facilities to adequately store patient samples and a Legionella risk assessment.

• Put into place a documented process to enable the GPs to effectively and safely triage patients based on information gathered by non-clinical staff.

• Provide all clinical staff with child protection and safeguarding training to the appropriate level; and confirm that staff are aware how to report concerns to external authorities.

• Put in place appropriate systems and processes to be able to respond to medical emergencies including access to equipment and a robust business continuity plan.

• Improve recruitment arrangements so that they include all necessary employment checks for all staff; and provide new staff with an induction.

In addition the provider should:

• Introduce a programme of quality improvement initiatives such as clinical audits and re-audits to improve patient outcomes.

• Introduce systems to ensure all clinicians are kept up to date with national guidance and safety alerts.

• Consider how to ensure patients have access to practice information in the reception area, including the practice leaflet and the complaints procedure.
• Review and update procedures and guidance including the significant events policy; and implement a chaperone policy.
• Record minutes of staff, clinical and multidisciplinary meetings.
• Review the outcomes of the 2016 national GP patient survey to determine appropriate action with a view to improving the patient experience.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

People agreed to the care and treatment received and provided their informed consent.

We found the GPs and clinical staff provided care and treatment for people with respect and dignity. One person told us they found the doctor "really helpful" and they felt "listened to". Another person told us when they contacted the service to make an appointment they found reception staff, "very efficient and was offered a number of appointment options".

The practice appeared visibly clean and there was a cleaning schedule for the clinical and non-clinical areas.

The service operated effective recruitment and selection processes. People were cared for, or supported by, suitably qualified, skilled and experienced staff.

The practice had in place systems for assessing and monitoring the quality of the service for people.