All inspections: Dr Anita Sharma - Care Quality Commission

We carried out an announced inspection at Dr Anita Sharma on 22 April 2021. Overall, the practice is rated as inadequate with the following key question ratings:

Safe - Inadequate

Effective - Inadequate

Caring - Good

Responsive – Requires improvement

Well-led - Inadequate

Previously, an inspection was carried out on n 14 June 2019. The practice was rated inadequate and placed into special measures. Two warning notices and a requirement notice were issued. We re-inspected the practice on 7 February 2020 and found the required improvements had been made. The practice was rated good overall and in all key questions, and it was removed from special measures.

On 20 January 2021 we carried out an unrated focused inspection. This was following a Transitional Monitoring Approach (TMA) assessment where possible risks to patient safety had been identified. We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued warning notices in respect of Regulation 12 (safe care and treatment) and 17 (good governance) and a requirement notice in respect of Regulation 19 (fit and proper persons employed).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Anita Sharma on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection of all five key questions. We followed up on the breaches of regulations we found in our previous inspection and also looked at areas of risk highlighted to us

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

Conducting staff interviews using video and telephone calls
Completing clinical searches on the practice’s patient records system and discussing findings with the provider
Reviewing patient records remotely to identify issues and clarify actions taken by the provider
Requesting evidence from the provider
A site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall and Inadequate for all population groups.

At this inspection, on 22 April 2021, we found the required improvements had not been made following the inspection on 20 January 2021. In addition, we identified further areas of concern.

We rated the provider as inadequate for providing safe services. Clinical staff were not correctly authorised to administer certain medicines. Some patients prescribed high risk medicines were not being appropriately monitored. Checks on the competence, training and experience of clinical staff were not routinely undertaken prior to them working at the practice. Not all pre-recruitment checks were carried out. Some significant event forms had been misplaced and full investigations had not been carried out.

We rated the provider inadequate for providing effective services. The on-going clinical needs of patients were not managed consistently due to required monitoring not always taking place. Patients with poor mental health had consultations with a pharmacist who had not provided evidence of being sufficiently trained. Patients with potentially missed diagnoses were found. No formal checks were carried out on the competence of clinicians.

We rated the provider good for providing caring services. Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the provider requires improvement for providing responsive services. Complaints were not handled in a satisfactory manner.

We rated the provider inadequate for providing well-led services. The practice had not made the improvements required following the inspection of 20 January 2021. Significant event and complaints information was missing so the practice could not confirm appropriate action had been taken. There was no Freedom to Speak Up Guardian and some staff had not heard of one. Some policies were inaccurate, lacked sufficient detail, or were not being followed. There was no system to identify staffing risks. The required training of clinical staff was not monitored. There was no system of quality assurance within the practice, and the governance systems in place were not effective in that safety risks had not been identified.

We found three breaches of regulations. The provider must:

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.
Ensure persons employed by the service provider are of good character, have the qualifications, competence, skills and experience which are necessary for the work to be performed by them and have all the information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Due to the breaches of regulation identified we will be carrying out further enforcement action against the provider.

I am again placing this service in special measures. The Care Quality Commission will refer to and follow its enforcement processes in taking action reflecting these circumstances.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out a focused inspection of Dr Anita Sharma on 20 January 2021. As part of the inspection our GP specialist advisor accessed the practice’s computer systems with the permission of the provider.

This inspection was carried out following a Transitional Monitoring Approach (TMA) assessment. The way we have worked during the Covid-19 pandemic has changed and the TMA is a new approach to regulatory monitoring.

Dr Anita Sharma was placed into special measures following an inspection on 14 June 2019. The practice was removed from special measures and rated good in all areas following an inspection on 7 February 2020. Our approach prior to the Covid-19 pandemic would have been to carry out a full comprehensive inspection 12 months after a practice was removed from special measures to ensure improvements had been maintained. Following the TMA assessment, a decision was made to carry out a focused inspection to review possible risks to patient safety.

We found that:

The current nurse and healthcare assistant were administering injections that they were not authorised to administer.
The required pre-employment information was not held for new members of staff.
Systems and processes to ensure good governance were not in place. For example, there was no process to ensure fridge temperatures were checked daily, or that urgent referrals were made as soon as the need was identified.
The practice had carried out a low number of annual reviews for patients with long-term conditions. However, the Covid-19 pandemic had an impact on how reviews were carried out.
The reviews carried out by regular locum staff did not always record the relevant information.
Repeat prescriptions were issued according to guidance.
Fit notes were issued according to guidance.

As this was a focused inspection, there is no change to the overall rating or any rating for any key question or population group. Our regulatory role and core purpose of keeping people safe has not changed and there is some action required by the provider.

The areas where the provider must make improvements are:

The provider must ensure care and treatment is provided in a safe way to patients.
The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider must ensure persons employed by the service provider are of good character, have the qualifications, competence, skills and experience which are necessary for the work to be performed by them and have all the information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The areas where the provider should make improvements are:

The provider should have a system in place to check locum staff are completing the correct level of reviews and documentation.
The provider should increase the number of long-term condition reviews carried out.

We have issued warning notices in respect of breaches to regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014, and also issued a requirement notice in respect of the breach of regulation 19 (fit and proper persons employed).

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We inspected Dr Anita Sharma, South Chadderton Health Centre, Eaves Lane, Chadderton, Oldham, on 14 June 2019 as part of our inspection programme. At the June 2019 inspection the practice was rated inadequate overall and placed into special measures. This was because it failed to make improvements that had been required following an inspection on 28 March 2018 when the practice had been rated requires improvement.

Following the June 2019 inspection, the following ratings were given:

Safe – Inadequate

Effective – Inadequate

Caring – Good

Responsive – Requires improvement

Well-led – Inadequate

Warning notices were issued in respect of breaches of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance) and Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and a requirement notice was issued in respect of Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed).

We carried out a focussed follow-up inspection on 14 October 2019 to check on the progress of the warning notices. We found improvements had been made in all areas but some were on-going.

This inspection was carried out on 7 February 2020. This was a full follow up inspection carried out six months after the report placing the practice into special measures was published. At this inspection we found that improvements had been made under each of the key questions and all the requirements of the warning notices had been sustained.

We have rated this practice as good overall and good for all key questions. All the population groups were rated good except families, children and young people, which was rated requires improvement due to childhood vaccination data.

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

Review the infection control audit and take action where required.
Fully record the relevant immunisation status of all staff.
Carry out an appraisal for the advanced nurse practitioner.
Fully adopt the new safeguarding policy and include practice information.
Amend the chaperone policy to reflect who could chaperone and check all chaperones had been trained.
Improve the level of child vaccination.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We inspected Dr Anita Sharma, South Chadderton Health Centre, Eaves Lane, Chadderton, Oldham, on 18 March 2018 as part of our inspection programme. The practice was given an overall rating of requires improvement with the following key question ratings:

Safe – Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement.

Requirement notices were issued in respect of breaches of Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (safe care and treatment), Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance), Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed).

On 14 June 2019 we carried out a further full comprehensive inspection of Dr Anita Sharma. The practice was given an overall rating of inadequate and placed in special measures. The key question ratings were:

Safe – Inadequate

Effective – Inadequate

Caring – Good

Responsive – Requires improvement

Well-led – Inadequate

Warning notices were issued in respect of breaches of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance), Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed).

This inspection, carried out on 14 October 2019, was to check the progress made with the warning notices.

We found that although some further improvements were still required, improvements had been made in all the required areas.

In particular we found:

The practice had reviewed and collated training information for all except one staff member. Where there had been gaps we found staff had updated their training. There was a new system for monitoring training.
The practice had not obtained training information for one nurse, who worked for one day a month, prior to the inspection. However, they obtained this on the inspection day and we saw it was up to date.
The practice had revised their system of carrying out staff appraisals. However, although the practice manager told us they took part in the appraisals this was not recorded on documents. They provider told us they would change this and ensure written input from the appraiser.
The practice was collecting all relevant information from new staff members prior to them starting work.
A Disclosure and Barring Service (DBS) check for a member of the clinical team who carried out home visits, that was outstanding at the previous inspection, had still not been received. This was discussed with the provider who told us they would monitor this and ensure it was actioned.
The practice kept records of relevant staff information including professional registration and vaccination status.
The practice had reviewed and reorganised their policies and procedures. We saw that all current documents were easy to access and previously inaccurate guidance had been archived.

The rating of inadequate awarded to the practice following our full comprehensive inspection on 14 June 2019 remains unchanged and the practice remains in special measures. A further full inspection of the service will take place within six months of the original report being published and their rating revised if appropriate.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We inspected Dr Anita Sharma, Chadderton South Health Centre, Eaves Lane, Chadderton, Oldham, OL9 8RG on 28 March 2018 as part of our inspection programme. The practice was given an overall rating of requires improvement with the following domain ratings:

Safe – Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement.

Requirement notices were issued in respect of breaches of Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (safe care and treatment), Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance), Regulation 18 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (staffing) and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 (fit and proper persons employed).

On 14 June 2019 we carried out a further full inspection at Dr Anita Sharma.

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

At the inspection of 14 June 2019 we found that the requirements of Regulation 12 had been met. However, we did not see improvements relating to Regulations 17, 18 and 19.

We have now rated this practice as inadequate overall and inadequate for all population groups.

We rated the practice as inadequate for providing safe services because:

Not all staff had been trained in safeguarding adults and children.
The practice did not carry out all the required checks prior to recruiting new staff, and there was no evidence of on-going checks. This had not been actioned following a requirement notice being issued after the March 2018 inspection.
Not all staff were trained in fire safety.
The recently completed infection control checklist had incorrectly stated it was confirmed all staff were trained in hand hygiene and Hepatitis B vaccinations were up to date for all clinical staff.
Some guidance documents for staff gave incomplete or incorrect information.
Significant events were not always discussed at the earliest opportunity, and learning from significant events was not always discussed with people involved in the event.

We rated the practice as requires inadequate for providing effective services because:

There was no evidence of an induction programme for some staff and the induction for other staff was not well-monitored. This had not been actioned following a requirement notice being issued after the March 2018 inspection.
Training identified as mandatory by the practice, including safeguarding and General Data Protection Regulations (GDPR), had not been completed by all staff. Training was not monitored to ensure it was updated in line with the practice’s policies. This had not been actioned following a requirement notice being issued after the March 2018 inspection.
There was no assurance that long-term locum GPs had received appropriate training. This had not been actioned following a requirement notice being issued after the March 2018 inspection.
Staff appraisals had been recently carried out. However there was no evidence that an appraiser had been involved in the appraisal; forms were completed by the staff member only and the manager kept no record. Following the inspection the provider provided evidence they had added in their comments that had not previously been included.

We rated the practice as good for providing caring services because:

Staff treated patients with kindness, respect and compassion. Feedback from patients was usually positive about the way staff treated people.
Staff helped patients to be involved in decisions about care and treatment.

We rated the practice as requires improvement for providing responsive services because:

The complaints policy contained incorrect information and the complaints flow-chart contained information from Scotland.
Responses to complaints did not contain information about how the complaint could be escalated if the complainant was not satisfied.
Learning needs identified following complaints were not monitored. We saw that a training need had been identified in June 2018 but not all staff had received the training by our inspection in June 2019.

We rated the practice as inadequate for well-led services because:

Regulation breaches in the well-led domain at the March 2018 inspection had not been actioned or had been repeated.
Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements had not improved since the last inspection.
The practice did not always act on appropriate and accurate information.
We did not see evidence of systems and processes for learning, continuous improvement and innovation going forward.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure persons employed by the service provider receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Ensure persons employed by the service provider are of good character, have the qualifications, competence, skills and experience which are necessary for the work to be performed by them and have all the information required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as requires improvement overall. (Previous inspection March 2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Dr Anita Sharma on 28 March 2018 as part of our inspection programme.

At this inspection we found:

The practice discussed significant events in meetings. However these events were not all documented and suggested improvements not monitored
Training and supporting staff had not been a priority and training records had not been kept up to date. It was unclear what training had taken place.
The practice until recently had used paper records and paper policies. This meant clear guidance was not readily available for staff and not all records were easy to locate. However, this had been identified by the new practice manager.
Following the two practice nurses and the practice manager leaving, a new practice nurse and new practice manager had recently started work. They were working to identify and solve issues relating to previous ways of working.
There was a patient participation group (PPG) who was working with the new practice manager to identify where improvements to the practice could be made.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and reported that they were usually able to access care when they needed it.

The areas where the provider must make improvements are:

The provider must ensure care and treatment is provided in a safe way to patients.
The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider must ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
The provider must ensure recruitment procedures are established and operated effectively so only fit and proper persons are employed. The provider must ensure specified information is available regarding each person employed.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

The practice of Dr Anita Sharma was inspected on 5 March 2015. This was a comprehensive inspection. This means we reviewed the provider in relation to the five key questions leading to a rating on each on a four point rating scale. We rated the practice as good in respect of being safe, effective, caring, responsive and well-led.

Our key findings were as follows:

The practice has a system in place for reporting, recording and monitoring significant events. Significant incidents and events are used as an opportunity for learning and improving the safety of patients, staff and other visitors to the practice.

The practice has systems in place to ensure best practice is followed. This is to ensure that people’s care, treatment and support achieves good outcomes and is based on the best available evidence.

Information we received from patients reflected that practice staff interact with them in a positive and empathetic way. They told us that they were treated with respect, always in a polite manner and as an individual.

Patients spoke positively in respect of accessing services at the practice. A system is in place for patients who require urgent appointments to be seen the same day.

We saw areas of outstanding practice including:

The practice patient participation group (PPG) had been active in the area of health promotion at the practice. They were very involved in helping to plan and facilitate regular health promotion events at the practice.

The practice had established links with local voluntary and third sector groups. For example the practice had established links with Age UK Oldham to promote health programmes for the recently retired. The practice had also worked closely with a local mosque to develop a health education programme.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider should:

The electronic patient records system alerted the GPs and other clinical staff when a safeguarding issue or safeguarding plan had been identified and developed for adult patients. The electronic patient records system did not however provide such alerts when a safeguarding issue or safeguarding plan had been identified and developed for children. Whilst this information was in the patients record to maximise the awareness of clinical staff the alert system should be extended to include children where safeguarding issues or a safeguarding plan have been identified or developed.

Whilst we acknowledge that the practice clinical team is relatively small and staff had a clear understanding of how to keep children and vulnerable adults safe it was not clear who the clinical lead was in respect of safeguarding at the practice. To ensure staff are clear on where they can access support regarding safeguarding matters, the practice should identify a clinical safeguarding lead and communicate who this person is to all staff.

The vast majority of prescriptions issued at the practice were computer generated. A system was in place to ensure the security of prescription forms against theft and misuse. One of the GPs was occasionally using a pre-printed prescription pad. The prescription pad had been issued to the GP in 2012 and was stored securely. It was not evident that a record was made of the serial numbers of the prescriptions on this pad. To maximise the security of prescription forms against theft and misuse the provider should ensure their prescription security checks include any pre-printed prescription pads.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Archived: Dr Anita Sharma Also known as Dr A Sharma, South Chadderton Health Centre

All Inspections

22 April 2021

During a routine inspection

20 January 2021

During an inspection looking at part of the service

7 February 2020

During a routine inspection

14 October 2019

During an inspection looking at part of the service

14 June 2019

During a routine inspection

28/03/2018

During a routine inspection

5 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)