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Dr Alok Mittal Inadequate Also known as Markyate Surgery

We are carrying out checks at Dr Alok Mittal using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Inadequate

Updated 7 December 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Alok Mittal also known as Markyate Surgery on 20 January 2017. The overall rating for the practice at that time was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Alok Mittal on our website at www.cqc.org.uk.

This report follows a further inspection undertaken following the period of special measures, and was an announced comprehensive inspection which took place on 28 September 2017. At the inspection we found insufficient evidence of improvement and we identified further serious concerns. Overall the practice is still rated as inadequate.

Our key findings were as follows:

  • Patients were at risk of harm because systems and processes were not implemented in a way to keep them safe. For example, we identified continuing deficiencies in respect of acting on safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA) and further serious concerns were identified in respect of monitoring patients on high risk medicines, communicating abnormal test results to patients and the processing of referrals.

  • Evidence showed that care and treatment was not always delivered in line with recognised professional standards and guidelines. For example, the review of patients with long-term conditions and those with a learning disability.

  • Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement. There was no evidence that the practice was comparing its performance to others; either locally or nationally.

  • Data from the national GP patient survey showed patients rated the practice lower than others for many aspects of care and they had in some cases got worse since our January 2017 inspection.

  • The practice identified and supported patients who were also carers, the number of carers identified had improved since our January 2017 inspection.

  • Data from the national GP patient survey showed patients rated the practice significantly below others in respect of access to the service and they had in some cases got worse since our January 2017 inspection.

  • Information about how to complain was available and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.

  • We had serious concerns about the overall leadership of the practice and their ability to facilitate and sustain 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.

In addition the provider should:

  • Consider ways to improve bowel and breast cancer screening uptake rates to bring in line with local and national averages.

  • Consider GP provision for access to a female GP.

This service was placed in special measures in March 2017. Insufficient improvements have been made such that there remains an overall rating of inadequate. Therefore we are taking 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for providing safe services and improvements must be made.

  • Patients were at risk of harm because systems and processes were not implemented in a way to keep them safe. For example, we identified continuing deficiencies in respect of acting on safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA) and further concerns were identified in respect of monitoring patients on high risk medicines and prescription pad security.

  • There was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice.

  • Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.

  • The practice had adequate arrangements to respond to emergencies and major incidents.

Effective

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for providing effective services and improvements must be made.

  • Evidence showed that care and treatment was not delivered in line with recognised professional standards and guidelines. For example, the review of patients with long-term conditions.

  • We identified continuing shortfalls in the review of patients with a learning disability. Although the provider took action after our inspection to rectify this.

  • Patient outcomes were hard to identify as there was limited evidence of clinical audit or quality improvement. There was no evidence that the practice was comparing its performance to others; either locally or nationally.

  • There was not a failsafe system in place to ensure abnormal test results were communicated to patients.

  • Evidence showed that referrals were not always made in a timely way.

  • There was limited engagement with other providers of health and social care.

Caring

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for providing caring services and improvements must be made.

  • Data from the national GP patient survey July 2017 showed patients rated the practice lower than others for many aspects of care and they had in some cases got worse since our January 2017 inspection.

  • Survey information we reviewed showed that patients felt they were not always treated with compassion, dignity and respect or involved in decisions about their care and treatment.

  • The practice identified and supported patients who were also carers, the number of carers identified had improved since our January 2017 inspection.

Responsive

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for providing responsive services and improvements must be made.

  • There was limited evidence that the practice engaged with the Clinical Commissioning Group (CCG) to discuss the needs of its population and secure service improvements.

  • Data from the national GP patient survey July 2017 showed patients rated the practice significantly below others in respect of access to the service and performance for some indicators had got worse since our January 2017 inspection.

  • The practice had good facilities and was equipped to treat patients and meet their needs. Although access to a female GP was not available.

  • Information about how to complain was available and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.

Well-led

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for being well-led.

  • The practice had a desire to provide high quality care however there was not an effective strategy or supporting business plans to deliver it.

  • The provider had not met all the requirements of a warning notice we issued following our January 2017 inspection. There were continuing deficiencies in the review of patients with long-term conditions and those patients with a learning disability, the prescribing of hypnotic medicines and responding to patient safety alerts.

  • There were some arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. However, we identified serious concerns in respect of high risk medicine monitoring, communicating abnormal test results to patients and the processing of referrals.

  • There was no programme of continuous clinical and internal audit to monitor quality and to make improvements. Some audits had been initiated in respect of prescribing however there was limited evidence that they had resulted in quality improvement.

  • Practice specific policies were implemented and were available to all staff. These were updated and reviewed regularly. However, there was no detailed policy for the management of patients on high risk medicines.

  • We had serious concerns about the overall leadership of the practice and their ability to sustain improvement.

Checks on specific services

Older people

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of older people. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • The safety of care for older patients was not a priority and there were limited attempts at measuring safe practice.

  • The practice did not carry out care planning for older patients who were approaching the end of life. The practice had one patient on the palliative care register and the register was updated when required.

People with long term conditions

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of people with long-term conditions. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • Structured annual reviews were not always undertaken to check that patients’ health and care needs were being met.

  • There were no personalised care plans in place for patients with long-term conditions and QOF performance for long-term conditions was significantly below average.

Families, children and young people

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of families, children and young people. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • Immunisation uptake rates were below local and national averages for all the standard childhood immunisations. However, unpublished data provided by the practice after the inspection showed they had achieved the 90% national target for all standard immunisations.

Working age people (including those recently retired and students)

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of working age people (including those recently retired and students). The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours and online appointment booking.

People whose circumstances may make them vulnerable

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • Not all patients with a learning disability had received an annual health check.

  • The practice did not identify those whose circumstances may make them vulnerable who were approaching the end of life.

  • Staff had been trained to recognise the signs of abuse in vulnerable adults and children.

People experiencing poor mental health (including people with dementia)

Inadequate

Updated 7 December 2017

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia). The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The issues identified as requiring improvement overall affected all patients including this population group.

  • The practice did not carry out advance care planning for patients with dementia.

  • There was no recorded evidence of patients being reviewed following a diagnosis of depression.