Dr Sankar Bhattacharjee - Care Quality Commission

Background to this inspection

Updated 10 November 2016

The practice is located in a residential street in Westcliff-On-Sea, near Southend, Essex. The practice serves a wide patient population with a high percentage of young people and those of working age. There is a high proportion of temporary social housing resulting in a transient population which translates into a high patient turnover for the practice. The practice also provides care to a growing aging population and conducts weekly visits to three local care homes for patients with limited mobility and high dependency needs.

The practice patient population on the day of our inspection was 3550 patients. The practice serves a deprived community, with higher representation of deprived children and older people than the local and national averages. The practice also has a lower life expectancy than the local and national averages for men.

The practice has one full time male GP and two additional GPs, one male locum GP and one female salaried GP. The lead GP provides eight clinical sessions a week, the locum three sessions and the female salaried two GP sessions. The female practice nurse works one day a week normally a Friday. The healthcare assistant works half days, Monday and Thursday providing phlebotomy services.

The practice is open between 8am and 6.30pm on Monday to Friday. The practice operates extended hours on Tuesday and Friday evenings until 8pm. The practice is open half day every Thursday 8am until 1pm for appointments but staff are on the premises until 6.30pm managing enquiries.

Appointments are available from 8.30am to 11am Monday to Friday. Phone consultations are held from 4pm to 4.45pm and evening surgery is held between 4.45pm to 6.30pm on Monday and Wednesday. On Tuesday and Friday evening consultations are from 4.45pm to 7.20pm. Appointments could be booked 2 months in advanced.

The practice holds a general medical services contract and has opted out of providing out-of-hours services to their patients. The practice told us the CCG arranges their out of hour’s provision and they advise patients to call the 111 service or attend the walk in centre.

The practice was first inspected on 18 November 2014. The practice attracted an overall rating of requires improvement and was assessed as inadequate in safe, requires improvement in effective, responsive and well led. It was rated as good for caring. Amongst the areas highlighted for improvement were the practices arrangements for identifying, recording and managing risks, their management of complaints, significant incidents and staff recruitment. The practice was also required to assess and monitor the quality of services and ensure effective systems were in place to assess the risk of and prevent, detect and control the spread of health care associated infections.

A follow up inspection was conducted on 30 September 2015. The practice attracted an overall rating of inadequate and was assessed as inadequate in safe, effective and well lead and requires improvement in caring and responsive. Conditions were also placed on the practice where areas of risk were identified and the practice was placed into special measures.

Overall inspection

Inadequate

Updated 10 November 2016

Letter from the Chief Inspector of General Practice

On 30 September 2015 we carried out an announced comprehensive inspection at Dr Sankar Bhattacharjee (also known as Westborough Road Health Centre). The practice was found to be inadequate for providing safe, effective, and responsive and well led services and required improvement for caring. As a result of the inadequate rating overall the practice was placed into in special measures for six months on 4 February 2016 due to insufficient improvements being made.

At this time we identified several areas of concern including:

Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.
Staff were not clear about identifying and reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
Staff had not received appropriate training in basic life support, or in safeguarding children and vulnerable adults.
Medicines had not been managed appropriately with records showing that vaccines had been stored in excess of the recommended temperatures potentially affecting their effectiveness.
There was insufficient assurance to demonstrate people received effective care and treatment. For example patient safety alert information had not been effectively actioned and patients continued to be prescribed medicine contrary to national guidance. The practice did not prepare or share patient care plans with out of hours providers to coordinate care. Patient clinical records were inaccurately summarised failing to identify conditions and clinical risks.
The practice did not have an induction programme for new non-clinical staff or a system or appraisals, meetings or reviews of staff performance.
The practice had recognised the diverse community they served but had not considered how best to deliver services to them to meet their needs.
Patients were unable to book appointments or order prescriptions online. However, urgent appointments were usually available on the day they were requested.
The practice had improved, since our last inspection in November 2014 their recording, investigation and response to complaints. However, risks to patient safety were not always identified and lessons learnt were not shared to improve practice.
There was insufficient leadership and an absence of strategy for the practice. The practice engaged with patients and listened to partner agencies developing action plans but failed to have the capacity to fulfil actions within acceptable timeframes and sustain improvements.

Practices placed into special measures receive another comprehensive inspection within six months of the publication of the report.

On 27 July 2016 we carried out an announced comprehensive inspection at Dr Sankar Bhattacharjee to check whether sufficient improvements had been made to take the practice out of special measures. We found sufficient improvements had not been made and the provider ratings remained as before to be inadequate for providing safe, effective, caring and well led services and required improvement for responsive.

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

We found significant incidents were not consistently identified, recorded, investigated and lessons learnt to mitigate reoccurrences.
Patient safety and medicines alerts had not been actioned presenting serious risks to patients.
Arrangements were in place to safeguarding children and vulnerable adults. However, not all members of the clinical team had received appropriate training and the practice did not follow up on the non-attendance of high risk groups for appointments.
The practice appeared clean and tidy. An infection prevention control action plan was in place, actions had been assigned but no dates for completion.
The practice had insufficient systems for the safe management of medicines including conducting timely reviews and safe prescribing.
Medical supplies were found to be out of date including needles in the emergency first aid kit.
Appropriate recruitment checks had been conducted on staff although many of the administrative staff references were personal as opposed to professional.
We found no legionella risk assessment had been conducted and incomplete records existed relating to health and safety risks and business continuity arrangements.
There was no evidence that some members of the clinical team had received appropriate basic life support training. There was no defibrillator available to staff or child mask for the oxygen or risk assessment in place.
The practice had poor clinical outcomes in QOF achieving 60% of the total points available. The local average is 90% and the national average 95%.
We found some clinical records were poor, lacking details of examinations and rationales for decisions. We found no care plans in place for patients identified on the practice admission avoidance register. The practice had also not maintained and reviewed the care of their palliative patients including preferred places of care.
The practice did not hold multidisciplinary meetings.
We found no evidence of the staff receiving a formal induction or training on consent of the Mental Capacity Act 2005. The practice nurse did not understand and was unable to demonstrate how the legislation applied to their role and responsibilities.
The practice had low uptake for the national screening programmes for cervical screening and breast and bowel cancer.
The practice did not identify or support carers by providing them with information on services available to them.
The practice operated extended hours on a Tuesday and Thursday. However, patients reported difficulty in accessing an appointment with the practice nurse who worked on Friday.
The practice did not have an effective system in place for handling complaints. They were acknowledged in a timely manner but not answered fully it was also unclear the outcome of the complaint.
The practice had a published vision to deliver high quality care. They also had a business plan but it lacked details of how and when they would achieve their objectives.
There was poor clinical governance of the practice. Risks were not being identified and there was no system of quality improvement through clinical audit or other means. Breaches of regulations identified at previous inspections had not been actioned and there was a lack of leadership in relation to driving improvement.
The Patient Participation Group spoke highly of the practice manager. However, they were unsure of their role in the absence of terms of reference. They were unable to provide examples of where the practice had engaged with them asking, listening and responding to feedback.

The areas where the provider must make improvement are:

Ensure the assessment and mitigation of risks. This includes the recording and investigation of significant incidents, management of patient safety alerts, the checking of medical equipment to ensure they are in date, the management of infection prevention control, health and safety risk assessment of the premises and equipment (including absence of access to emergency lifesaving equipment), legionella risk assessment and risks if there is disruption to services.
Ensure the proper and safe management of medicines, so patients receive timely and appropriate medicine reviews and checks.
Ensure patients receive care and treatment appropriate for their needs, in accordance with NICE and reflecting their preferences such as end of life care decisions.
Ensure staff are trained and understand consent and Mental Capacity Act 2005, including how this relates to their role and responsibilities.
Ensure staff receive appropriate training (including in safeguarding, basic life support and infection prevention control) to perform their roles and responsibilities.
Establish an effective and accessible complaints system.
Ensure patient records are accurate, complete and a contemporaneous record.
Ensure clinical oversight, assessing, monitoring and improving the quality and safety of services such as through clinical audits and the experiences of service users (PPG).
Identify the patients who are carers, keep records and provide appropriate support and guidance.
Ensure improved clinical performance in QOF and national screening programmes.
Ensure personal beliefs of clinical staff do not delay patients receiving timely and appropriate care (e.g. access to contraceptive services).
Ensure the defibrillator is working and accessible to staff and there is an oxygen mask available for children.

The areas where the provider should make improvement are:

Follow up on children and vulnerable adults who fail to attend appointments.
Support the practice nurse with revalidation.
Ensure multidisciplinary working especially in the review and management of care plans for vulnerable patients.
Ensure arrangements exist to assisted entry for patients to the premises with mobility issues, where required.
Ensure appropriate references are obtained for new staff to the practice.

However, following this inspection on 27 July 2016 our findings and our proposed enforcement action was shared with the provider, they then returned their NHS England contract to provide primary medical services and cancelled their registration with the Care Quality Commission. This meant they were no longer providing services at the practice and therefore it was unnecessary to take enforcement action.

Since the inspection, the practice has closed and the patients are attending alternative GP practices within the local area.

Professor Steve Field (CBE FRCP FFPH FRCGP)