Archived: The Monteiro Clinic North

This service is not rated in this inspection. There were two previous inspections. The first inspection was carried out on 17 April 2019, when the service was rated as inadequate overall and for providing safe, effective or well led care. It was rated as requires improvement for caring and responsive. Following the inspection warning notices were issued, and a condition was put in place which prevented nursing staff working across any sites operated by the provider.

A further unrated inspection was carried out on 4 July 2019, where we found that the service was not providing safe, effective, caring, responsive or well led services. We found that:

• Although the service had a policy in place to manage patients who had been prescribed high risk medicines, we found serious concerns regarding the management of patients prescribed these medicines.
• We found concerns regarding the management of patient care which was not provided in accordance with best practice and national guidance.
• Practice nurses had not undertaken specific role training or been competency checked and we found they had been working whilst subject to an urgent condition imposed the Care Quality Commission to prevent them from doing so.
• There was limited evidence of a safe system and processes in place regarding safeguarding children and vulnerable adults.
• The clinical IT system at the practice systems were difficult to audit, and doctors at the practice seemed unaware where on the patient record to include information.
• There was a lack of clinical governance and oversight for patient care.
• The service did not recognise or record all significant events.
• The service did not have an adequate clinical audit system in place to ensure quality improvement.

On the basis of this inspection, a condition was placed on the provider’s registration so that it could not provide medical care at this location.

We carried out this announced focussed inspection at The Monteiro Clinic on 24 September 2019. The provider had provided information about changes they had made to systems which they said addressed the concerns raised in the report of 4 July, and which were also relevant to another service (Monteiro Clinic Limited), which had been prevented from providing clinical care on an inspection of 10 July. The purpose of this inspection was to allow the provider an opportunity to detail those areas where improvements had been made, and for CQC to review these systems prior to a formalised appeal of the cessation of medical care at these two services.

We found that:

• The service had appointed a new Clinical Director in order to address the issues of poor practice detailed in the last inspection which led to conditions being placed on the provider’s registration.
• The provider did not have formalised plans in place to address all of the areas of concern found in the inspection of June 2019.
• Formal governance procedures in place at the time of the inspection, or formally planned subsequently, were not sufficient to assure CQC that safe and effective care could be provided.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

This service is not rated in this inspection. (There was one previous inspection. The first on 17 April 2019 rated the practice as inadequate. It was rated as inadequate for safe, effective and well led care, and requires improvement for caring and responsive care.)

We carried out an announced inspection at the Monteiro Clinic North to follow up on the previous inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Following the inspection, we acted immediately regarding: and imposed an urgent condition on the provider by issuing a s.31 notice under the Health and Social Care Act 2008 regarding:

• Regulation 12 Safe care and treatment.
• Regulation 17 Good governance

This condition prevented the provider from operating medical services with immediate effect.

The Monteiro Clinic Limited is an independent provider of medical services and offers a full range of private general practice services predominantly to the Brazilian, Portuguese and Spanish communities. The service has a sister practice in Clapham, South London.

Dr Monteiro is the lead clinician and the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were :

• The service had a policy in place to manage patients who had been prescribed high risk medicines. However, we found further serious concerns regarding the management of patients prescribed these medicines.
• We found concerns regarding the management of patient care that was not provided in accordance with best practice and national guidance.
• Practices nurses had not undertaken specific role training or been competency checked and we found they had been working whilst subject to an urgent condition to prevent them from doing so.
• There was limited evidence of a safe system and processes in place regarding safeguarding children and vulnerable adults.
• The clinical IT system at the practice was difficult to audit and doctors at the practice seemed unaware where on the patient record to include information.
• All GPs’ had undertaken safeguarding training at an appropriate level.
• The service did not have an Import Licence for medicines imported from Portugal.
• Yellow Fever vaccines had been administered to patients, but the service was not registered as a Yellow Fever Centre.
• There was a lack of clinical governance and oversight for patient care.
• The service did not recognise or record all significant events.
• The service did not have an adequate clinical audit system in place to ensure quality improvement.

At this inspection we found that the practice had addressed some of the issues from the warning notices. However, we noted that there were areas that had not been addressed, and a clinical records review showed clinical care which was inadequate.

We found that:

• The service did not provide care in a way that kept patients safe and protected them from avoidable harm.
• Patients did not receive effective care from clinicians at the practice, and there were inadequate systems to ensure that staff were fit for the role they were undertaking and the management of consent.
• The way the practice was led and managed did not promote the delivery of high-quality, person centre care. There was a lack of governance systems, protocols and systems to provide safe and effective care.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure systems and processes are established and operated effectively to ensure compliance with the requirements of good governance.

Following the previous inspection of 17 April 2019, this service had warning notices placed against it. Insufficient improvements have been made to ensure that patients were receiving safe, effective and well led care. We have also found significant concerns about the care being provided to patients through clinical record review. Therefore, we are acting in line with our enforcement procedures to prevent the provider from operating medical services and may only provide dental services at this location. We have taken immediate action to prevent the provider from providing regulated services from this location.

Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care.

We carried out an announced comprehensive inspection on 17 April 2019 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

This service is rated as Inadequate

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? – Inadequate

We carried out an announced inspection at the Monteiro Clinic North under Section 60 of the

Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Following the inspection, we took action immediately regarding the practice nurses and imposed an urgent condition on the provider by issuing a s.31 notice under the Health and Social Care Act 2008. This condition prevented the practice nurses from operating until they were appropriately trained and competency checked to carry out the roles they were employed to perform.

We issued the provider with two Warning Notices under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

•Regulation 12 Safe care and treatment.

•Regulation 17 Good governance.

The Monteiro Clinic Limited is an independent provider of medical services and offers a full range of private general practice services predominantly to the Brazilian, Portuguese and Spanish communities. This is the first inspection of the service. The service has a sister practice in Clapham, South London.

Dr Monteiro is the lead clinician and the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

As part of our inspection, we asked for CQC comment cards to be completed by patients prior to our inspection. We received 13 completed CQC comment cards which were all positive about the level of service and the care provided, and patients felt that they were treated with dignity and respect. We did not speak with patients directly at the inspection.

Our key findings were:

•Practices nurses did not have the required training, knowledge and experience to carry out the roles they were undertaking.

•There was limited evidence of system and processes in place regarding safeguarding children and vulnerable adults.

•Not all GPs’ had undertaken safeguarding training at an appropriate level.

•The service did not have a system or policy in place to safely manage patients who had been prescribed high risk medicines.

•Staff had not undertaken training to enable them to screen patients for red flag signs.

•The service did not have an Import Licence for medicines imported from Portugal.

•Yellow Fever vaccines had been administered to patients but the service was not registered as a Yellow Fever Centre.

•There was a lack of clinical governance and oversight for patient care.

•The service did not recognise or record all significant events.

•The service did not have an adequate clinical audit system in place to ensure quality improvement.

•The provider was aware of their responsibility to respect people’s diversity and human rights.

•Patients could access care and treatment from the clinic within an appropriate timescale for their needs and information leaflets were available in Spanish, Portuguese and English.

•Staff told us the service offers new patients a free health check consultation.

We identified regulations that were not being met and the provider must make improvements regarding:

•Care and treatment must be provided in a safe way for service users.

•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).

I am placing this service in special measures. 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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care