Background to this inspection
Updated
22 September 2016
Dr David Zigmond is part of Southwark Clinical Commissioning Group (CCG) and serves approximately 1,420 patients. The practice is registered with the CQC for the following regulated activities Diagnostic and Screening Procedures and Treatment of Disease, Disorder or Injury.
The practice population has a high proportion of male patients and lower proportion of female patients compared to the national average. There are higher number of patients of working age and over the age of 75 when compared nationally. The practice is located in the third most deprived decile on the index of multiple deprivation.
The practice is run by a male principal GP. There is one male salaried GP and one male nurse. The practice offers ten GP sessions per week.
The practice is open between 8.00 am and 6.30 pm. The practice offers booked and emergency appointments five days per week. The practice does not have a website though patients can book appointments online and request repeat prescriptions online via the NHS choices website.
Dr David Zigmond operates from St James Church (North Aisle), London, Southwark
SE16 4AA which is located within a church. Access to the church is through a separate door and the surgery operates independently from the church building.
Practice patients are directed to contact local out of hours provider when the surgery is closed.
The practice operates under a Personal Medical Services (PMS) contract, and is signed up to the enhanced service which aims to facilitate timely diagnosis and support for people with dementia.
The practice is part of Quay Health Solutions which is a local GP federation.
Updated
22 September 2016
Letter of the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr David Zigmond on 5 July 2016. Overall the practice is rated as inadequate.
On the basis of our findings we made an application to Camberwell Magistrate’s Court on 11 July 2016 to urgently cancel the provider’s registration under section 30 of The Health and Social Care Act 2008 on the basis that there were several breaches of the 2014 Regulations which presented serious risks to people's life, health or well-being. including:
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Lack of emergency equipment
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Staff did not adequately assess consent and capacity
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The processes for managing and prescribing patient medication did not keep patients safe
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The processes in place to record and learn for significant events were not effective
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The practice’s procedures around child and adult safeguarding did not ensure that vulnerable people were kept safe.
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The practice did not comply with a number of current medical guidelines and best practice.
Other key findings across all the areas we inspected were as follows
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Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks had not been undertaken for staff prior to their employment and actions identified to address concerns with infection control practice had not been completed.
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Non-medical equipment had not had portable appliance testing since 2013 and there was no assessment of whether or not this equipment was safe to use.
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There was no oxygen or defibrillator on the premises. Staff at the practice told us of two instances where patients had collapsed in or near the surgery and no staff had completed basic life support training within the last 12 months. Staff had not received fire safety training, there was no completed fire safety risk assessment and the fire alarm was broken. Though the practice had business continuity arrangements in place the GP principal had no awareness of these.
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Systems around medicines management and treatment of patients with long term conditions or mental health concerns were inadequate. There was no effective system in place to ensure that patients were recalled for reviews and treatment provided often did not reflect current best practice and guidance. The outcome of which was reflected in the practice’s poor performance in a number of clinical areas relative to other practices nationally and locally.
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There were inadequate systems in place to safeguard people against abuse or harm and a number staff had no DBS certificates.
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Staff were not clear about reporting incidents, near misses and concerns. We identified several instances where significant events were not acted upon in accordance with practice policy.
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Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
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There was no evidence of patient or staff feedback being used to drive improvement.
Our application was successful and Dr Zigmond’s registration with the Care Quality Commission was cancelled on 11 July 2016
Had the provider’s registration not been cancelled, we would have set out the following list of ‘musts’ for their action:
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Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
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Assess and take action to address identified concerns with infection prevention and control
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Ensure recruitment arrangements include all necessary employment checks for all staff.
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Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines and ensure that these are being followed consistently.
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Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
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Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
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Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
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Ensure that adequate records are produced for each patient and that effective systems are put in place to ensure that patients are recalled and reviewed when required.
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Put in place appropriate systems to safeguard vulnerable children and adults.
Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice
People with long term conditions
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.
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Practice nurse availability in the practice was limited. We asked the GP principal several questions about the management of patients with diabetes and asthma but were told that these were the nurse’s responsibilities and they were unaware of how these patients were managed. There was no evidence of any structured clinical supervision for the nurse.
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Diabetes indicators for 2014/15 were in line with national averages. Data provided by NHS England suggested that management of diabetic patients had deteriorated in 2015/16.
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Longer appointments and home visits were available when needed.
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There was no evidence of effective systems of recall in place for patients with long term conditions.
Families, children and young people
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.
- The practice systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances were inadequate. We were told that patients who were discharged from A&E were not followed up by staff at the practice.
- Immunisation rates were relatively high for all standard childhood immunisations.
- The percentage of women aged 25-64 whose notes recorded that a cervical screening test has been performed in the preceding 5 years was 58% compared with 80% locally and 82% nationally. The practice had recently hired a female nurse to hold a monthly cervical screening clinic, as the health centre they previously referred patients to had closed down. We were told that this clinic was fully booked until September 2016. Prior to this there had been no female clinician working at the practice.
- Appointments were available outside of school hours. However there were no baby changing facilities and the premises were not suitable for those who had young children in pushchairs.
- The GP principal told us that they never met with health visitors.
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.
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Care and treatment of older people did not always reflect current evidence-based practice.
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The practice did not make effective use of palliative care pathways where required.
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Access for patients with mobility needs was poor due to the layout of the building.
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The leadership of the practice had little understanding of the needs of older people and were not attempting to improve the service for them. Services for older people were therefore reactive, and there was a limited attempt to engage this patient group to improve the service.
Working age people (including those recently retired and students)
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.
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The practice did not have a website though patients could book appointments online and order repeat prescriptions online via NHS choices.
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The practice offered no extended hours appointments though we were told that the practice had received feedback from patients who had asked for extended hours appointments.
People experiencing poor mental health (including people with dementia)
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.
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The practice identified patients experiencing poor mental health and those with dementia.
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We were told that the practice held regular meetings with a counsellor from the local mental health team though there was no evidence of this multi-disciplinary working in the case management of people experiencing poor mental health.
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A review of records highlighted deficiencies in respect of the practice’s system for recalling patients for review. For example we reviewed the records for one vulnerable mental health patient who was documented as requiring monthly reviews. However this patient had not been seen since December 2015 and there was no evidence that this patient had been contacted or attended an appointment since.
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The practice did not carry out advance care planning for patients with dementia. The practice did not have a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. Practice patients had 20% higher rate of A&E attendances than CCG average. The GP principal was unable to explain why A&E attendances were higher and there was no evidence of any analysis being undertaken to try and identify the causes of higher attendance rates. We reviewed one record where a patient had attended A&E as a result of a medicine overdose however there was no detail of the incident or records received from the hospital recorded on the system.
People whose circumstances may make them vulnerable
Updated
22 September 2016
The provider was rated as inadequate for safety, effectiveness, and well led and as requires improvement for caring and responsive resulting in the practice being rated as inadequate overall. The issues identified as being inadequate overall affected all patients including this population group.