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Archived: Dr SS Sapre and Partners Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 March 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr S S Sapre & Partners on 13 January 2016. Overall the practice is rated as requires improvement.

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

  • The practice had a system in place for the management of Medicines and Healthcare Products Regulatory Agency (MHRA) alerts. However, there was a delay of up to one week before these were shared with clinicians. These alerts were not held for future reference.

  • Arrangements for managing medicines kept patients safe.

  • The practice had completed a number of clinical audits which evidenced safe prescribing.

  • Assurances given by the provider in response to the findings of an infection control audit at the practice had not been acted upon.

  • At the time of inspection, the practice was carrying vacancies for a health care assistant and a permanent GP.

  • Staff recruitment checks were incomplete; a number of staff had not received an induction and some staff had not received the appropriate employment contracts.

  • There was no oxygen available for use on site. The practice manager pointed to the availability of oxygen at neighbouring facilities but could not confirm or show there was an agreement in place for shared use of oxygen.

  • No care plans were in place for patients aged over 75 who may be more vulnerable to ill health .

  • Dementia screening was being done opportunistically. There was no plan in place to show how all patients identified as being at risk of dementia, would be effectively screened in a timely manner.

  • The practice did not have an efficient system in place to manage the health checks for patients aged 40-74 years.

  • Complaints submitted to the NHS Choices website were not followed up and acted upon. All complaints were not recorded.

  • The registration of the practice with the Care Quality Commission did not reflect the way in which the practice was run; the lead GP was present at the practice for two clinical sessions each week. Evidence from our inspection showed that this was insufficient to maintain overall direction and control of the practice.

There were areas were the provider MUST make improvements. The provider must:

  • Ensure care plans are in place for patients aged 75 and over.

  • Ensure there is access to oxygen for use in medical emergencies.

  • Improve systems in place for the management and sharing of MHRA alerts.

  • Effectively address points raised in the infection control audit by Liverpool Community Health.

  • Record, investigate and respond to all complaints made about the practice, whether they are verbal or written, or registered on the NHS Choices website.

  • Keep sufficient records in relation to staff recruitment.

  • Keep sufficient records in relation to the management of regulated activities.

  • Address issues around the registration of the practice.

There were areas were the provider SHOULD make improvements. The provider should:

  • Provide a hearing loop facility for those patients with impaired or reduced hearing.

  • Review all patient deaths (death audit) to ensure patients wishes around final place of care are observed.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the provision of safe care and treatment.

Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe.

  • Medicines and Health Products Regulatory Agency (MHRA) alerts were shared with staff, but we noted delays of up to a week in doing this. These alerts were not held for future reference. We saw evidence that the practice was reliant on the medicines management team to recall and review patients medication in response to MHRA alerts.

  • Arrangements for managing medicines kept patients safe.

  • We found the practice premises to be clean and tidy. An infection control audit undertaken in July 2015 by Liverpool Community Health recommended that fabric curtains be laundered every six months and a spare pair kept to use in case of spillage, or that they be replaced with disposable ones. The practice had provided assurances that this would be addressed but had failed to act on this.

  • Staff recruitment checks were incomplete; there were no references in place for key staff or health questionnaires and many staff had not received an induction.

  • There was no oxygen on site. The provider said that oxygen was available in the community health centre next door and held at a dentist nearby. There was no evidence of a shared use agreement, or that staff knew the exact location of the oxygen.

  • There were no spillage kits available to practice staff. The provider said these were available from the community health centre, linked to the practice building but staff did not know the exact location of these and could not find the key to the cupboard the items were stored in.

Effective

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the provision of effective services.

  • There were no care plans in place for patients aged over 75, other than those in nursing homes, which the nursing home staff had produced.

  • There were no designated clinical leads within the practice other than for safeguarding. For example, there was no one GP who took the lead in the review and care of patients with learning disabilities or for patients with poor mental health.

  • Although clinicians had all received recent training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, one GP had difficulty explaining the provisions of this legislation and on how it could impact on their daily work.

  • Dementia screening was done opportunistically. There was no plan in place which demonstrated screening in line with expected prevalence, or showing that all patients at risk of dementia would be screened in a timely fashion.

  • The systems in place to ensure all patients aged between 40 and 74 years received a health check were unclear as the figure given by the practice of 273 health checks delivered was in respect of patients from both practices.

  • The GP on call each day reviewed discharge letters for patients who had been admitted to hospital unexpectedly. There was no discussion of unplanned admissions or coverage of this subject as a standard agenda item on practice clinical meetings. GPs decided whether to contact the patient by phone or face to face.

  • We saw that some audits were conducted by the practice, for example, a methotrexate audit and an opiate prescribing audit which showed monitoring of high risk medicines.

  • The provider had recruited a healthcare assistant who would assist the nurse at the practice on a part time basis. The practice was seeking to recruit a permanent GP for the practice but there was no live advertisement for this post either internally or externally. Few staff had received an appraisal. Staff files were incomplete, for example, some staff had not received an appraisal or induction.

  • Not all staff had been given contracts of employment.

Caring

Good

Updated 31 March 2016

The practice is rated as good for providing caring services.

Our findings were:

  • We received 32 CQC comment cards, completed by patients before our inspection. Of these, 29 gave positive feedback. Three gave negative feedback which was around waiting times when patients had arrived for their appointment, errors in repeat prescribing and about lack of onward referral for treatment of more persistent health problems.

  • There was no routine review of patient deaths (death audit); the practice did not send sympathy cards but said sometimes they would make a phone call to bereaved carers or family members.

  • In the last GP Patient Survey 56% of respondents would recommend the practice to people new to the area, compared with an average score for the same question amongst other practices locally of 69% and 78% nationally; and

  • 84% of respondents said they had confidence and trust in the last GP they spoke to, compared with an average score for the same question amongst other practices locally of 94% locally and 95% nationally.

Responsive

Good

Updated 31 March 2016

The practice is rated as good for the provision of responsive services.

The practice provides an extended hours surgery on a Tuesday evening.

Due to the way in which the practice was run, it was not possible to determine how staff were allocated to each practice patient list, in terms of availability of GPs and number of appointments available and whether this was truly sufficient to meet patients needs.

There were longer appointments available for patients with a learning disability. Same day appointments were available for children and those with serious medical conditions. Patients were able to receive travel vaccinations available on the NHS.

There was no induction hearing loop available at the practice for patients with limited hearing.

A Patient Participation Group (PPG) had recently been set-up and had met for the first time in the last three months.

Well-led

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for providing well-led services.

  • The registration of the practice with the Care Quality Commission did not reflect the way in which the practice was being run. The provider was unable to demonstrate that they were in overall direction and control of the practice on a day to day basis.

  • We saw a lack of clear, direct leadership which could guide staff through changes which had been made at the practice since its acquisition by Dr Sapre in 2012.

  • Although an administrator had been appointed to support the practice manager, the division of duties was unclear. This hindered the practice in moving forward.

  • An IT problem had not been dealt with effectively and had not been brought to a resolution by practice leaders.

Checks on specific services

Older people

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care of older people. The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The older patient population was slightly higher at the practice, than that of other practices in England. The practice offered pre-bookable appointments up to seven days in advance and appointments could be booked on-line. We were told that the ordering of repeat prescriptions on-line had been problematic, and the practice had not effectively addressed this issue. There were no care plans in place for patients aged over 75 who may have required more support.

People with long term conditions

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care of people with long term conditions. The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The nurse had a lead role in chronic disease management. Longer appointments were available to those that needed them and home visits were available for housebound patients. The practice recognised that they needed a health care assistant to support the work of the nurse.

Families, children and young people

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care and treatment of families, children and young people. The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The practice had a policy to see any child under five on the day, when this was required. The practice has access to Food Vouchers for use at a local foodbank, for those patients deemed to be classed as in urgent need.

Working age people (including those recently retired and students)

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care and treatment of working age people, including those recently retired and students. The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The practice did not have an efficient system in place to manage the health checks for patients aged 40-74 years. At the time of inspection, the practice had completed 273 health checks on patients aged 40-74 years but could not say whether these were patients of the practice we were inspecting, or of a practice based in the same building which is also owned by Dr Sapre & Partners. The practice gave the figure of 273 health checks completed on patients between 40-74 years, out of a total patient list for the two practices of approximately 4,800 patients.

Immunisation rates were high for all standard childhood immunisations. Appointments were available outside of school hours and the premises were suitable for children and babies. The practice took part in a number of screening programmes; we saw that the rate of screening for bowel cancer at the practice was slightly higher than the local CCG and England average. The numbers of women between the ages of 50 and 70 who had been screened for breast cancer in the last three years was in line with rates for the local CCG and England average.

People whose circumstances may make them vulnerable

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care and treatment of people whose circumstances may make them vulnerable. The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The locum GP at the practice (who had been working for the practice for a considerable time) said registers were in place for vulnerable patients. The practice had a lead for safeguarding of children and vulnerable adults and all staff knew who this was. Safeguarding registers were kept by the practice.

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 31 March 2016

The practice is rated as requires improvement for the care and treatment of people experiencing poor mental health (including people with dementia). The ratings of requires improvement in the domains of safe, effective and well-led impacted on all population groups.

The practice was screening patients at risk of dementia on an opportunistic basis. There was no plan in place that showed how all patients would have access to this screening in a timely manner. The practice had a mental health register and care plans were in place for these patients.