Archived: Brixton Water Lane Practice

Updated 5 July 2016

Brixton Water Lane Practice is part of Lambeth CCG and serves approximately 6184 patients. The practice is registered with the CQC for the following regulated activities Diagnostic and Screening Procedures; Family Planning; Treatment of Disease, Disorder or Injury and Maternity and Midwifery Services.

The practice population has a larger proportion of patients of working age and a lower proportion of patients over 65. The practice has a similar number of infants under the age of ten compared to the national average. The practice is located in an area which ranks in the third most deprived decile on the index of multiple deprivation. There are higher numbers of people in full time employment and fewer unemployed than the national average. The percentage of those with a long term condition is also lower than the national average.

There are two GP partners (one female, one male) as well as three salaried GP’s (two female and one male) There are two female practice nurses.

The practice is open between 8 am and 6.30pm Monday to Friday and appointments are available between 9am and 12pm and 2pm and 6 pm. The practice offers whole time equivalent of four and a half full time GPs with booked and emergency appointments five days per week.

The Brixton Water Lane Practice operates from Water Lane Surgery, London, Lambeth

SW2 1QE which is a converted residential property owned by one of the existing partners at the practice and a former partner. The service is accessible for patients with mobility problems. However we were told that those patients who required the use of a wheelchair needed to get assistance from reception staff to access the building as there are no automatic doors.

Practice patients are directed to contact the 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 a number of local and national enhanced services (enhanced services require an enhanced level of service provision above what is normally required under the core GP contract). These are: Childhood Vaccination and Immunisation Scheme, Facilitating Timely Diagnosis and Support for People with Dementia, Influenza and Pneumococcal Immunisations, Learning Disabilities, Remote Care Monitoring, Rotavirus and Shingles Immunisation and Unplanned Admissions.

The practice is part of South East Lambeth GP federation.

Updated 5 July 2016

We carried out an announced comprehensive inspection at Brixton Water Lane Surgery on 28 April 2016. Overall the practice is rated as requires improvement.

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

• There was an inconsistent approach to the reporting and management of significant events with some staff not being aware of the practice’s significant event procedure and others not being included in learning from events. We found evidence that not all significant events were managed under the practice’s process.

• Risks to patients in respect of infection control, fire safety, recruitment and staffing and response to emergencies were inadequately assessed and managed.
• In the majority of respects staff assessed patients’ needs and delivered care in line with current evidence based guidance and had the skills, knowledge and experience to deliver effective care and treatment. However we saw several examples where assessments were either not undertaken or not compliant with current legislation and guidance around capacity and consent.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice was not easily accessible or ideally suited to patients with mobility problems, young children or those with hearing impairment. There had been no assessment undertaken of the suitability of the premises for these patients.
• Although there was a leadership structure in place some staff were uncertain of who acted as leaders in certain areas.
• Practice policies were not always tailored to practice requirements and some contained out of date or insufficient information.
• Staff told us they felt supported by management. The practice acted on feedback provided by staff.
• The practice did not offer online appointments.
• The practice did not have a functioning Patient Participation Group and we saw no evidence of the practice obtaining feedback from their patient population.
• The provider was aware of the Duty of Candour though we only saw the practice disclose information to patients when they complained. The practice was unable to provide any example of a patient safety alert that it had acted on.

The areas where the provider must make improvement are:

• Ensure that consent and capacity is assessed and the outcome of any assessment documented in accordance with legislation and guidance.

• Ensure that there are adequate systems in place for the receipt, distribution and management of relevant patient safety alerts and for reporting and managing significant events and that appropriate action is taken including notifying patients who may be affected. Ensure that all policies and procedures meet the requirements of the practice and contain all required contemporaneous information. Ensure annual infection control audits, legionella risk assessment, regular fire risk assessments and a risk assessment for staff whose DBS certificates have expired are carried out and that risks identified are addressed. Ensure that all prescriptions are stored securely and there is a system in place for monitoring their use.

• Ensure that appropriate pre-employment checks are completed and that professional registrations are periodically monitored.

• Ensure that all staff have received mandatory training including safeguarding and fire safety.

The areas where the provider should make improvement are:

• Review staffing levels and ensure that there are always sufficient numbers of staff on the premises to adequately meet patient need.

• Continue to monitor the arrangements in place to deal with emergencies and major incidents including always having a full stock of emergency medicines on the premises and a business continuity plan which is up to date and comprehensive

• Continue to improve identification and management of patients with long term conditions.

• Ensure that quality improvement initiatives including audits clearly demonstrate learning and improvement.

• Consider how to involve all staff in regular meetings and ensure that key issues, actions and learning are recorded and shared.

• Ensure all clinical staff complete Mental Capacity Act training.

• Review the accessibility of the premises and opportunities to make reasonable adjustments particularly for those with reduced mobility and those with young children.

• Advertise the available translation services in the waiting area.

• Offer online appointments.

• Put a clear documented leadership structure in place and ensure that all staff are aware of this.

• Engage with the practice’s patient population and use feedback in the practice’s decision making process related to service provision.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice 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

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• The majority of diabetes indicators were comparable to national averages with the exception of the one area. The practice had engaged with the community diabetic team and reviewed all patients who had poor medication compliance in a virtual clinic but told us that this had not improved patient compliance.

• Longer appointments and home visits were available when needed.

• Virtual clinics were held with the support of community pharmacists with the aim of optimising patient medication for those with a number of long term conditions including Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation and Hypertension.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care; although we saw limited evidence that these meetings were minuted.

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• There were systems in place 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.

• Immunisation rates were relatively high for all standard childhood immunisations.

• The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months, was higher than the national average.

• Conversations with staff confirmed that not all clinicians were treating children and young people in an age-appropriate way.

• The number of patients who had received a cervical screening test within the preceding five years was comparable to the national average.

• Appointments were available outside of school hours.

• The practice waiting area was small and not ideally suited to those parents and carers who had pushchairs.

• We were not provided with any evidence of examples of joint working with midwives, health visitors or school nurses and were told that staff rarely met with health visitors.

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• The practice participate in the Holistic Health Assessment Scheme; providing assessments of elderly and housebound patients followed up with a comprehensive care plan which engaged support from a range of local health and social care services; including those from the voluntary sector.

• The practice held a virtual clinic with a Community Geriatrician.

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. However the practice did not allow patients to book online appointments though they had the facilities to do so.

• The practice provided an online repeat prescription service as well as a full range of health promotion and screening that reflects the needs for this age group.

• The practice did not offer extended hours access within the surgery but could book patients into the local hub which was run through the GP Federation and offered appointments from 8 am till 8 pm seven days per week.

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• 95% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which is higher than the national average.

• Other mental health indicators were similar to national averages.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia though we saw no evidence of these meetings being minuted.

• The practice carried out advance care planning for patients with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• We reviewed one record of a patient who presented with pre dementia symptoms. The notes stated that there was implied consent to discuss the care of this patient with a close relative. No formal consent or capacity assessment was present on the record to support this decision.

• The practice participated in the GP plus scheme where they reviewed all patients on their list who had been recently discharged by the community mental health team.

Updated 5 July 2016

The provider was rated as inadequate for safety and requires improvement for effective, responsive and well led resulting in the practice being rated as requires improvement overall. The issues identified as requiring improvement overall affected all patients including this population group. There were, however, examples of good practice:

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people though minutes of meetings were not always documented.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding documentation of safeguarding concerns. However we saw evidence in one of the practice’s meeting minutes that they were not aware of who to contact at the relevant agencies as at 25 April 2016.