Dr Sergio De Cesare - Care Quality Commission

Background to this inspection

Updated 14 September 2017

Dr Sergio De Cesare (known locally as Cherry Tree Surgery) is located in a converted terraced house on the borders of Barnet and Haringey and is a part of Barnet Clinical Commissioning Group (CCG). The practice has good transport links and there is free parking on the surrounding roads.

There are approximately 3,300 patients registered at the practice, 40% of patients have a long standing health condition, which is lower than the CCG and national averages of 49% and 54%. The practice also has a higher proportion of patients in paid work or full time education than the national average at 78% compared to the CCG average of 66% and the national average of 62%. Eleven percent of the practice population is aged over 65; this is lower than the CCG average of 14% and the national average of 17%.

The practice provides nine GP sessions per week and two nursing sessions per week. There is a practice manager who is supported by the caretaking practice and three reception/administration staff members.

The practice operates under a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the most common form of GP contract).

The practice is open Monday to Friday between 8am and 6:30pm except Thursdays when the practice closes at 1pm to complete administration tasks. Phone lines are answered from 8am and appointment times are as follows:

Monday 9am to 12pm and 3pm to 5pm
Tuesday 9am to 11pm and 3pm to 5pm
Wednesday 9am to 11pm and 2:15pm to 5pm
Thursday 9:10am to 12:30pm
Friday 9am to 11am and 3pm to 5pm

The locally agreed out of hours provider covers calls made to the practice whilst the practice is closed including directing patients to services such as 111.

Dr Sergio De Cesare operates regulated activities from one location and is registered with the Care Quality Commission to provide family planning, surgical procedures, treatment of disease, disorder or injury, maternity and midwifery services and diagnostic and screening procedures.

Overall inspection

Inadequate

Updated 14 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sergio De Cesare on 4 and 10 January 2017. The overall rating for the practice was inadequate and the provider was suspended for six months, a care taking practice was allocated to the practice and the practice was placed in special measures. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Sergio De Cesare on our website at www.cqc.org.uk.

This inspection was undertaken following the period of suspension and special measures and was an announced comprehensive inspection on 6 July 2017. Overall the practice is still rated as inadequate.

Our key findings were as follows:

The practice had a significant events policy. However not all members of staff were able to locate it on the practice’s computer system and no events had been recorded even though we were given recent examples of significant events.
The practice had some policies and protocols but these were not fully embedded in practice and not all staff members were able to locate them.
The practice had no vulnerable adults or safeguarding children register and not all staff members knew where to access the safeguarding policy. Staff members were unclear of who the safeguarding lead for the practice was and were unclear of the external safeguarding team contacts or when to use them.
There were no systems to act on and mitigate risks associated with patient safety alerts.
All staff had completed mandatory training but this had not been embedded into practice.
Although the practice participated in the Quality and Outcomes Framework (QOF) no data had been submitted and they could not demonstrate how this was being monitored. Therefore the practice was unable to demonstrate outcomes and quality improvement for patients with long term conditions.
There had been no audits undertaken since the last inspection, where we were shown one incomplete audit with no evidence of how action led to improvement.
The process for prescribing repeat medicines did not always include a review of high risk medicines; for example we saw that mesalazine was prescribed without any recent blood tests.
The practice had a system for monitoring the cold chain; however we found out of date typhoid and nasal flu vaccines in the vaccine fridges.
Emergency medicines did not include ceftriaxone, (this is used for patients who are allergic to penicillin) and there was no water for injection.
The practice did not use an interpreting service for patients who did not have English as a first language and did not use their hearing loop.
There was no practice website, and online services such as appointment booking and prescription requests were not available.
There were discrepancies about what was classified as a complaint and how these were recorded and responded to.
Staff who acted as chaperones were trained for the role and had received disclosure and barring service checks; however they were unable to demonstrate that they could carry out the role effectively.
There was minimal engagement with other providers of health and social care; the practice did not participate in any peer review or multidisciplinary meetings.
There was no evidence of appraisals or personal development plans.
The practice had identified none of its patients as a carer.
The practice told us that they carried out monthly formal practice meetings; however other than a meeting that occurred in response to the inspection announcement, these were not documented, there were no agendas, minutes or noted actions for learning and improvement.
The business continuity plan was not comprehensive and incomplete and the practice had not secured a buddy practice.
The practice had a recently formed patient participation group and was in the process of gathering patient feedback.
We saw that Legionella testing had been carried out.
All electrical and clinical equipment had been tested and calibrated to ensure that it was fit for purpose and in good working order.
Patient Group Directions (PGD) had been adopted by the practice to allow nurses to administer medicines in line with legislation. PGD’s are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.
There were systems in place to ensure the regular monitoring of the defibrillator and oxygen in the practice.
There was a failsafe mechanism for cervical cytology to ensure all test results were received by the practice and all inadequate tests were followed up.

There were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
Ensure patients are protected from abuse and improper treatment.
Ensure care and treatment is provided in a safe way to patients.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

Ensure that all patients are treated with dignity and respect.
Maintain appropriate standards of hygiene for premises and equipment.
Review the system for promoting the availability of chaperones in the practice.
Consider re-introducing a carers register with processes to identify carers so that sufficient support can be provided to them.

The provider of this service was suspended for six months, a care taking practice was put in place and the practice was placed in special measures in January 2017.

There had been some improvements made but more improvement was needed. The practice remained with a rating of inadequate and in special measures but the suspension was allowed to expire as it was recognised that the practice was unable to effectively bring about the changes required with the care taking practice in place.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of 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 to 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 by adopting our proposal to remove this location or 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