Dr B Bhatti & Dr R Das Also known as Bermondsey Spa Medical Practice

We carried out an announced comprehensive inspection at Dr B Bhatti & Dr R Das (also known as Bermondsey Spa Medical Centre) on 01 October 2019.

At this inspection we followed up on breaches of regulations identified at our last comprehensive inspection on 23 January 2019. At that inspection, we rated the practice inadequate overall, as sufficient improvements had not been made from the previous inspection 10 July 2018 where the practice was placed into special measures. Due to 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. 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 requires improvement overall.

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

• The practice did not have all recommended emergency medicines or a risk assessment for not having them all.
• The practice was not monitoring the vaccine refrigerator when staff were absent.
• Not all staff were up to date with safeguarding training.

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

• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance.
• There was evidence that the care of patients in two population groups (families, children and young people and working age people (including those recently retired and students) did not meet national targets or was below average.

We rated the practice as good 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 had taken action in response to the national GP survey and had undertaken their own survey.
• The practice had identified 4.8% of the practice list as carers.

We rated the practice as requires improvement 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.
• The practice results for the national GP survey were below local and national averages.
• Since the last inspection the practice had taken various steps to address feedback about difficulties accessing services, including recruiting more staff, utilising four staff members on the phones at busy times, monitoring the call system which they were not doing before. Also utilising the Patient Participation Group (PPG) and undertaking an internal patient survey. The practice had already started to receive feedback from patients, and PPG members that they had seen an improvement with access, this was also reflected in some of the comment cards, however at the time of the inspection we had not seen evidence of sufficient improvement.

We rated the practice as requires improvement for providing well-led services because:

• The practice had made improvements since our inspection on 23 January 2019 and had addressed the breaches we found at our previous inspections in relation to regulated activities currently provided in the practice.
• The practice had implemented a number of changes and had actions underway to improve care, but these had not yet led to evidence of sufficient improvement.
• Staff mentioned there were communication barriers and felt although the management listened they did always provide feedback or outcomes to requests.

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

The areas where the provider must make improvements 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.

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

The areas where the provider should make improvements are:

• Monitor emergency medicine and undertake risk assessments as required.
• Continue to monitor staff training needs.
• Review information provided for bereaved patients.

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

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

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