The Care Quality Commission
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Archived: Dr Masud Prodhan Also known as Old Trafford Medical Practice

Overall: Inadequate read more about inspection ratings

Seymour Grove Health Centre, Manchester, Greater Manchester, M16 0LW (0161) 848 7563

Provided and run by:
Dr Masud Prodhan

All Inspections

23/07/2019

During a routine inspection

This practice is rated as Inadequate overall. (Previous ratings: October 2016 Requires Improvement. September 2017 – Good)

The Doctor Masud Prodhan practice (known as Old Trafford Medical Practice) was initially inspected in July 2016 and awarded a rating of requires improvement in the Safe, Effective and Well Led areas. Concerns were around clinical safety, poor outcomes for patients and staff wellbeing. When the practice was re-inspected in September 2017 the concerns had been addressed and staff wellbeing appeared to have been resolved. During 2018, relationships between core members of staff in the practice became strained and key members of medical and managerial staff left. The practice was then in a period of instability until new management was secured in January 2019. In April 2019 the CQC received whistle blowing information from existing and from previous members of staff.

The CQC undertook an annual regulatory review because of the concerns and a decision to bring forward a full comprehensive inspection was agreed. The inspection was part of our regulatory functions to check whether the provider was maintaining the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. We looked at all the domains and all the key questions at this inspection.

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.

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

  • The practice did not have clear systems and processes to keep patients safe. . We found concerns around incident reporting, safeguarding, clinical record keeping, patient safety alerts, prescription protocols, and information sharing.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • The practice did not have appropriate systems in place for the safe management of medicines. Administration, pharmacy and health care staff were working outside their competencies.
  • Patient consultations were not sufficiently documented to ensure that appropriate information was available to all clinicians reviewing patients. There were gaps in alert processes for safeguarding and no evidence that information about safeguarding incidents was communicated to all clinical staff.
  • Staff were not clear about reporting incidents, near misses and concerns and the practice did not learn and make improvements when things went wrong.

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

  • There was limited monitoring of the outcomes of care and treatment. Data showed that some patient outcomes were positive but there were areas of high exception reporting.
  • There were areas of significant negative variation in relation to antibiotic prescribing and prescribing of medicines that are addictive.
  • There were several significantly negative responses from patients in the GP patient survey around access, appointments and the way they had been cared for.
  • The practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
  • The practice was unable to demonstrate that it always obtained consent to care and treatment.

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

  • Although staff dealt with patients with kindness and respect not all patients felt involved in decisions about their care.
  • Not all comments from patients were positive about their interactions with staff.
  • Verbally reported concerns were not escalated so that they could be dealt with and learned from.
  • Carers were not proactively identified and cared for appropriately.
  • We identified some patients who were offered treatment without appropriate explanation and this treatment was not within The National Institute for Health and Care Excellence (NICE) guidelines.

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

  • The practice was unable to organise and deliver services to meet patients’ needs.
  • Not all patients receiving care and treatment in a timely way.
  • Care and treatment were being provided on a reactive basis and clinics were being cancelled at short notice due to planned or unplanned periods of absence because of inconsistent locum cover.

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

  • There was insufficient practice leadership and leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • Leaders were not performing tasks intrinsic to their role and the requirements of the Health and Social Care Act.
  • At the time of the inspection the Provider was absent from the practice at the request of NHS England.
  • At this inspection we identified concerns that put patients at risk.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups, so we rated all population groups as inadequate.

(Please see the specific details on action required at the end of this report).

The areas where the provider must make improvements are:

  • Ensure that leaders can properly perform tasks that are intrinsic to their role
  • Ensure that all patients are treated with dignity and respect
  • Ensure care and treatment is provided in a safe way to patients
  • Ensure patients are protected from abuse and improper treatment
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure specified information is available regarding each person employed and any such action as is necessary and proportionate is taken when any member of staff is no longer fit to carry out their duties

We have suspended the Provider’s registration from 29 July 2019 for a period of three months when the situation will be reviewed.

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

11 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Masud Prodhan (also known as) Old Trafford Medical Practice on 29 July 2016. The overall rating for the practice was requires improvement and the practice were given a period of twelve months to make improvements. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Old Trafford Medical Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the period of time provided for the practice to make improvements and was an announced comprehensive inspection on 11 July 2017. Overall the practice is now rated as Good.

Our key findings were as follows:

  • Since the previous inspection the provider had introduced a significant number of systems and processes to improve safety, effectiveness and leadership at the practice. It was evident that the systems were embedded into every day working practice and were being followed.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Learning and improvement from incidents were evidenced and thorough analysis was taking place.

  • The practice used proactive methods to improve patient outcomes. Following an increase in excess of 1500 patients from another practice, two data quality clerks were recruited and new systems were introduced. Data from 2015/2016 evidenced that the practice met or exceeded targets for risk reduction and treatment in most of the indicators.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. For example, as part of their involvement in Productive General Practice a “choose well” system was introduced

  • The surgery was working closely with two local cancer screening providers to increase cancer awareness and a champion was introduced within the practice. The practice could evidence an increase in the uptake of cancer screening because of this intervention.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services. They increased the number of telephone appointments, recruited new reception staff and provided customer care training as a consequence of feedback from patients and from the patient participation group.

  • There was a clear practice vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. All staff were aware of, and signed up to the practice ethos and values.
  • The practice had introduced strong and visible clinical and managerial leadership and governance arrangements. All staff felt supported by management and complied with the duty of candour.

We saw areas of outstanding responsiveness :

  • The number of patients with long term conditions, particularly diabetes, increased substantially due to a neighbouring practice closure.The team responded by identifying all those patients with poorly managed diabetes and providing structured education plans with regular monitoring.They were able to evidence a positive impact on the number of patients with poorly managed diabetes that were now being well-managed and required less input from primary and secondary services.

  • Known patients who were hard of hearing had direct access to communicate by email with the medical secretary who arranged appointments and interpreters if and when required. We saw positive feedback from a patient in relation to this service.

  • As a result of the need to identify and support all genders within the community, clinical and non-clinical members of the team signed up to the pride in practice award run by the lesbian, gay, bisexual, and transgender (LGBT) foundation. Additional questions introduced to the new patient registration form helped to identify patients and offer advice and support that may not otherwise have been sought. The practice had received a Gold Award for their interventions.

In addition, there were areas of practice where the provider could continue to make improvements. The provider should:

  • Introduce a standardised agenda for meetings involving all staff to include items such as safeguarding, significant events and practice developments.

  • Review significant events trends more frequently than annually and include review dates on documentation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29th July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Old Trafford Medical Practice on 29th July 2016. Overall the practice is rated as requires improvement.

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

  • The practice was under pressure following recent major staff changes and we saw a fragmented leadership structure. Action had been taken to provide lines of management and structure for staff and continuity of care for patients.
  • Not all staff understood what constituted a significant event and did not always report them. Communications were raised through electronic notifications and then transferred to learning logs; there was no analysis of trends or confirmation that learning was achieved.
  • Collective clinical and staff face to face meetings were not regularly taking place to discuss where things went wrong and what could be done to stop them happening again in the future. Discussions were not documented.
  • The practice was located in a building where health and safety was managed by NHS Property Services. The practice communicated with the health and safety or community managers when risks were identified. There were good facilities and the building was well equipped to treat patients and meet their needs.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was information on the practice website about how to make a complaint and this could be translated into different languages. The practice took appropriate action when complaints or concerns were received.
  • Patients were happy with access and could make appointments easily with a named GP. The practice tried to offer continuity of care and urgent appointments were available on the day they were requested.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • The provider must ensure that the systems in place to formally record and report significant events is consistently followed and that all staff understand their responsibilities to raise concerns and to report incidents and near misses

  • The provider must address the fragmented leadership structure to ensure that good governance is maintained, risks and issues are identified and addressed and communication is consistent.

  • The practice must ensure that there are planned clinical audits taking place in order to drive improvement and achieve better outcomes for patients

The areas where the provider should make improvements are :

  • The practice should satisfy themselves that knowledge of policies, procedures and lead roles are consistent across all staff.

  • The practice should complete all planned staff appraisals.

  • The practice should review and analyse complaints to identify trends and learning points.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

19 December 2013

During a routine inspection

The Old Trafford Medical Practice is a small GP practice with 2100 registered patients based within Seymour Grove Medical Centre. There were three GP's, one nurse and one health care assistant working at the practice.

Patients we spoke to told us: 'Doctors are very good, very nice and soft. I see both Doctors and both are very good' and 'Reception are very good at accommodating appointments, never had any problems here.' Another patient told us: 'They know you, very personal, they take time. If you have on-going issues, they chase up for you and make referrals, there is never any issues referring you to specialists.'

We looked at five patients' electronic records and noted where verbal or written consent was required this had been recorded.

Patients' records were in chronological order and gave details of the most up to date consultation, with details of assessments, treatments, referrals and test clearly recorded.

We saw clear policies and procedures were in place for protecting children and vulnerable adults as well as a policy relating to domestic abuse. These policies were easily accessible to staff via the computer system in both consultation rooms.

The practice was clean and tidy. We found the practice had appropriate hand gel dispensers in both consulting rooms and reception area. Personal protective clothing was available for staff in consulting rooms.

During our visit we found the practice had systems to assess and monitor quality.