Archived: Dr Samuel Bhasme Also known as The Surgery Railway Street

We carried out an announced comprehensive inspection at Dr Samuel Bhasme on 11 July 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in July 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out a second announced comprehensive inspection at Dr Samuel Bhasme on 20 March 2018. The overall rating for the practice remained inadequate and the practice was placed in special measures for a further period of six months. A Warning Notice was served in relation to breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance, found at this inspection. The full comprehensive report on the March 2018 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in March 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the Warning Notice.

We carried out an unannounced focussed follow-up inspection on 19 June 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 March 2018. The practice was not rated as a consequence of this inspection.

As our inspection on 19 June 2018 found that the practice had not fully met the Warning Notice issued on 12 April 2018 and we therefore imposed conditions on Dr Samuel Bhasme’s registration with the Care Quality Commission. The conditions were:

Condition One: the registered person must not register any new patients at Dr Samuel Bhasme without the written permission of the Care Quality Commission unless those patients are newly born babies, or are newly fostered or adopted children of patients already registered at Dr Samuel Bhasme.

Condition Two: the registered person must submit to the Care Quality Commission, on a monthly basis, copies of significant events management and fire safety management action plans, including dates for completion of each action.

After the inspection in June 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was undertaken following the second period of special measures and was an announced comprehensive inspection carried out on 9 October 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections on 20 March 2018 and 19 June 2018. This report covers findings in relation to those requirements.

Overall the practice remains 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? – Inadequate.

Are services well-led? – Inadequate.

At this inspection we found:

• Improvements to the systems, processes and practices that helped to keep patients safe and safeguarded from abuse were insufficient.
• The practice had not made sufficient improvements to the assessment and management of risks to patients, staff and visitors.
• Information to deliver safe care and treatment to patients was not always available to staff.
• Improvements to the arrangements for managing medicines to help keep patients safe were insufficient.
• Staff did not report significant events they had been made aware of through feedback left on the NHS Choices website.
• The practice was still not keeping records of action taken (or if no action was required) in response to receipt of all notifiable safety incidents.
• Not all staff were up to date with essential training.
• Feedback from patients was not always positive about the way staff treated them.
• Results from the national GP patient survey showed that the practice was consistently below local and national averages for its satisfaction scores on the helpfulness of reception staff.
• A practice website had been created.
• Patients were not always able to access care and treatment from the practice within an acceptable timescale for their needs.
• The practice was unable to demonstrate they had an effective system to manage complaints and concerns.
• Improvements to governance arrangements at the practice had taken place but were insufficient.
• Improvements to processes for managing performance were insufficient.
• The practice had not formed a patient participation group.

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.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• 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.

Following two consecutive periods of special measures, insufficient improvements have been made such that there remains a rating of inadequate for providing safe, effective, responsive and well-led services as well as for all patient population groups. We will now move to close the service by cancelling the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Samuel Bhasme on 11 July 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in July 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out a second announced comprehensive inspection at Dr Samuel Bhasme on 20 March 2018. The overall rating for the practice was inadequate and the practice was placed in special measures for a further period of six months. A Warning Notice was served in relation to breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 Good Governance found at this inspection. The full comprehensive report on the March 2018 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After our inspection in March 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the Warning Notice.

This inspection was an unannounced focussed follow-up inspection carried out on 19 June 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 March 2018. This report only covers findings in relation to those requirements. The practice was not rated as a consequence of this inspection.

At this inspection we found:

• The practice was unable to demonstrate there was a consistent approach to their management of significant events.
• There was insufficient evidence of learning and improvement within the practice from significant events.
• There was insufficient evidence of improvements to the assessment and management of risks to patients, staff and visitors in relation to fire safety.

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

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

As our inspection on 19 June 2018 found that the practice had not fully met the Warning Notice issued on 12 April 2018 we imposed conditions on Dr Samuel Bhasme’s registration with the Care Quality Commission. The conditions were:

Condition One: the registered person must not register any new patients at Dr Samuel Bhasme without the written permission of the Care Quality Commission unless those patients are newly born babies, or are newly fostered or adopted children of patients already registered at Dr Samuel Bhasme.

Condition Two: the registered person must submit to the Care Quality Commission, on a monthly basis, copies of significant events management and fire safety management action plans, including dates for completion of each action.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Samuel Bhasme on 11 July 2017. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Dr Samuel Bhasme on our website at www.cqc.org.uk.

After the inspection in July 2017 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was undertaken following the period of special measures and was an announced comprehensive follow-up inspection carried out on 20 March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 11 July 2017. This report covers findings in relation to those requirements.

Overall the practice remains rated as inadequate.

The key questions are rated as:

Are services safe? – Inadequate.

Are services effective? – Inadequate.

Are services caring? – Good.

Are services responsive? – Requires improvement.

Are services well-led? – Inadequate.

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

• The practice had not made sufficient improvements to:
  • the system for reporting, recording and investigating significant events.
  • the systems, processes and practices that helped to keep patients safe and safeguarded from abuse.
  • the management of infection prevention and control.
  • the assessment and management of risks to patients, staff and visitors.
• Further improvements to medicines management were still required.
• The practice did not have adequate arrangements for responding to emergencies.
• Staff were now assessing patients’ needs and delivering care in line with current evidence based guidance.
• Data from the Quality and Outcomes Framework (QOF) demonstrated that the practice was performing in line with local and national averages for patient outcomes with the exception of diabetes related indicators.
• The practice had a system for completing clinical audits.
• Records showed that staff had received appraisals and GPs had revalidated or had a planned revalidation date. However, sufficient support to meet the practice development needs of all staff was not being provided.
• Records showed that all staff were now up to date with training in chaperoning, safeguarding vulnerable adults, infection prevention and control as well as fire safety.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients we spoke with said they were able to book an appointment that suited their needs. Pre-bookable, on the day appointments, home visits and a telephone consultation service were available. Urgent appointments for those with enhanced needs were also provided the same day.
• Information about services and how to complain was available and easy to understand. However, the practice was unable to demonstrate that learning from complaints had taken place.
• There was a clear staffing structure. However, not all staff were fully aware of their own roles and responsibilities.
• Improvements to governance arrangements were insufficient.
• The practice was able to demonstrate they had improved performance. However, further improvements were still required.
• The practice had systems for notifiable safety incidents. However, they did not always keep records of action taken (or if no action was necessary) in response to receipt of all notifiable safety incidents.
• There was a leadership structure and staff felt supported by management.
• The provider was aware of and complied with the requirements of the duty of candour.
• There had been no patient participation group meeting since our last inspection in July 2017.
• There was insufficient evidence of learning and improvement within the practice from significant events and verbal complaints.

The areas where the provider must make improvements are;

• 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 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 areas where the provider should make improvements are;

• Carry out Disclosure and Barring Service (DBS) checks, or risk assessments, for all staff who act as chaperones.

• Improve the system that monitors blank prescription forms throughout the practice.

• Record the checking of the automated external defibrillator and medical oxygen.

• Continue to implement plans to create a practice website.

• Include all relevant policies and protocols in the system that keeps governance documents up to date.

This service was placed in special measures in July 2017. Although improvements have been made these are insufficient such that there remains a rating of inadequate for safe, effective, well-led and all patient population groups. I am placing the service into special measures for a further six months.

Services placed into special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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 six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice