Archived: Dr Julius Sodipo Also known as Leigh Beck Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Julius Sodipo also known as Leigh Beck Surgery on 2 September 2015. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. Staff reported incidents, near misses and concerns however there was insufficient evidence of thorough investigation and identified learning or sharing of lessons to mitigate events reoccurring.
• Staff had understood their responsibilities in relation to safeguarding children. Staff lacked understanding and awareness of adult safeguarding, which they had not received training in.
• There was insufficient assurance that risks to patients had been identified and appropriately managed. Some staff who undertook chaperone duties had not received training and had not been subject to appropriate checks.
• The premises were clean and tidy however the infection prevention control audit to identify risks to patient safety had not been revised since 2010 and staff had not received training to mitigate risks.
• Medicines had not been managed appropriately. The medication stock records were inaccurate. Records viewed showed the vaccination fridge temperatures had exceeded recommended storage for medicines potentially compromising the integrity of the medicines. Staff did not recognise, report and respond to risks appropriately.
• Patients received effective care and treatment. For example, the practice performed in line with or exceeded the CCG and national averages for cervical screening and conducting childhood immunisations.
• Patients were positive about their interactions with reception staff, but reported receiving a poor service from the GP. This was acknowledged by the GP, who had not responded to the findings of the National GP patient Survey 2015.
• Patients told us they were able to get appointments at a time convenient to them. Urgent appointments were available on the day they were requested. However, the reception staff told us the practice was closed for non-urgent clinical appointments on a Friday afternoon.
• Complaints were investigated but there was insufficient analysis and learning was not shared with staff to mitigate the risks of incidents reoccurring.
• The practice had a clear leadership structure, but the GP was divorced from the practice team, not attending team meetings or speaking with staff regularly, to provide guidance or share learning. There was no commitment to learning or continuous improvement.

The areas where the provider must make improvements are:

• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure there are systems or processes established and operating effectively to assess, monitor and mitigate risks.
• Ensure the safe management of medicines.
• Ensure staff receive appropriate support, training, professional development, supervision and appraisal as necessary to carry out their duties.
• Ensure all recruitment checks are conducted and evidenced appropriately.
• Ensure the complaints policy is reflective of practice, affording patients access to advocacy services and right of appeal against decisions.
• Ensure sufficient equipment and medicines to care for basic and immediate care needs of staff and patients.

The areas where the provider should make improvements are:

• Provide clear leadership to staff to deliver improvements.
• Record the movement of all prescription pads.

I am placing this practice in special measures. Practices 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 practice 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 vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice