Archived: Dr Tom Frewin Also known as Clifton Village Practice

Updated 5 November 2015

The provider Dr Tom Frewin, of the location Clifton Village Practice is situated in a residential area of the city of Bristol. The practice had approximately 2,300 (September 2015) registered patients from the Clifton area. Based on information from Public Health England the practice patient population were identified as having a low level of deprivation. The practice did not support any patients living in care or nursing homes.

The practice is located in a Victorian adapted large former private residence. The practice is accessible via six steps up from street level. There are four floors within the building and a basement. There is a consulting room, reception, waiting room and office on the ground floor. A further consulting/meeting room is on the first floor. A consulting room, treatment room and meeting room is situated in the basement. There is no lift. The practice is on a primary medical service contract with Bristol Clinical Commissioning Group.

The provider is Dr Tom Frewin, services were provided at the one location of Clifton Village Practice:

52 Clifton Down Road, Clifton, Bristol. Avon. BS8 4AH

The practice had patients registered from all of the population groups such as older people, people with long-term conditions, mothers, babies, children and young people, working-age population and those recently retired; people in vulnerable circumstances who may have poor access to primary care and people experiencing poor mental health.

Recent information from the practice shows that the main population group registered at the practice were working-age and recently retired.

The practice consisted of an individual GP who was registered as the provider. The provider had engaged locum GPs to cover clinical support each day. GP locums were male or female and for some there were set working days but for others there were no set days per week when they attended the practice. There was also a regular a locum practice nurse who provided one session per week. Since the provider had been suspended from providing a service in June 2015 the provider had instigated contractual agreements with two GPs to provide on-going clinical support at the practice for when the practice re-opens.

The provider (an individual GP) had not undertaken any clinical activity since March 2014 therefore there was no monitoring, support or supervision provided to the locum GPs or locum nurse. There was no clinical oversight or at the practice. The practice building was open to patients during the whole of the working day from 9 am up to 6.30 pm and until about 7.15 pm on days when there were extended hours appointments. Prior to suspension of services, the appointments for extended hours ran from 6.30 pm to 7.00 pm on three evenings per week, usually Mondays, Tuesdays and Wednesdays. The day of the week could vary according to GP availability. There was open surgery every morning between 9 am and 10.30 am and anybody arriving between those hours would be seen. Appointments were available on every weekday afternoon. The practice referred patients to another provider, BrisDoc for an Out of Hours service to deal with any urgent patient needs when the practice was closed. Details of what the practice provided were included in their practice leaflet and answerphone message. The provider did not have a website to inform patients of the Out Of Hours arrangement.

Updated 5 November 2015

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Dr Tom Frewin, Clifton Village Practice on 1 September 2015. This was the fifth inspection at this practice since 15 April 2015.

This practice remains inadequate following this focussed inspection.

This inspection was to check that the warning notices served on 15 May 2015 regarding previous non-compliance had been met. We found that the provider had taken some steps but they had not taken sufficient action to comply with the warning notices and the risks for patients’ health, safety and wellbeing remained a concern. The practice was not providing a service to patients at the time of this inspection due to the suspension of the provider’s registration, imposed by us on 19 June 2015. This report should be read in conjunction with the report of the comprehensive inspection undertaken on 15 April 2015.

On 15 April 2015: A Comprehensive inspection was undertaken. At this inspection a number of significant areas of high risk concerns for patients were found. This was in respect of patient health, safety and wellbeing.

Following the inspection on 15 April 2015 we also issued six requirement notices in respect of the following areas, we told the provider they must:

• Ensure the practice environment is accessible in regard to meeting the Equality Act 2010.
• Ensure patients consent is obtained and recorded before treatment is provided.
• Ensure the practice has effective systems in place for cleaning.
• Ensure that persons employed at the practice receive the appropriate support, training, supervision and appraisal to carry out their role.
• Ensure there are safe recruitment procedures in place and sufficient staff employed to meet the needs of patients.

These will be reviewed by us when we next undertake a comprehensive inspection in December 2015.

On the basis of the findings at the inspection on 15 April 2015 we placed the provider into special measures. (Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid having its registration cancelled).

On 15 May 2015 we issued two warning notices to the provider. We outlined the identification of risks and our concerns for patients. The provider was given until 29 May 2015 to take remedial action and comply with these notices.

On 16 June 2015 a follow up, focussed inspection was undertaken to review the actions taken by the provider. We found very little action had been taken and we had continued concerns for the safety and welfare patients.

On 19 June 2015 we suspended the provider’s registration until the 17 July 2015. This was to give the provider time to take the required actions and rectify those immediate risks to patients’ safety and welfare.

On 15 July 2015 a follow up inspection was undertaken. This was in order to check that the warning notices served on 15 May 2015 had been met. We found that the provider had taken some steps but they had not taken sufficient action to comply with the warning notices and the risks for patients’ health, safety and wellbeing remained a concern. Due to continued risks to patients and to allow the provider additional time to make improvements we made a decision to extend the period of suspension of the provider’s registration until 3 September 2015.

At this inspection we found the following:

• The practice had made arrangements and had developed initial plans in order to provide clinical cover and clinical leadership at the practice should they be in a position to reopen and provided direct care to patients. We found that these plans were not robust as there were not enough staff to meet the needs of the practice population or to provide safe leadership and clinical governance.
• The practice had set up a system of patient recall. This was to provide regular health monitoring for all patients with long term conditions. However, we were unable to test if the system that had been set up was effective because whilst the suspension of the provider’s registration was in place no patients were being seen.
• The practice had taken some steps to implement safe working practices, develop key policies and procedures and to provide training for staff at the practice. However, we were unable to test if these were effective and would meet the needs of patients. This was because; due to the suspension of the provider’s registration the practice was not providing a service directly to patients at the time of this inspection.

Specifically we found the practice continues to require improvement for caring and inadequate for safe, effective, responsive well led services. Services provided to all population groups remain inadequate.

We are currently considering other enforcement options to ensure the systems, processes procedures and clinical governance arrangements proposed by the provider meet the needs of patients who are vulnerable and have a long term health condition.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 11 June 2015

The practice is rated as inadequate for the care of people with long-term conditions. There were risks to patients’ safety and a lack of evidence to show the service was safe and well led in all population groups.

Longer appointments and home visits were available when patients needed them. Areas of concern in regard to safety were recruitment, infection control, medicine management, management of equipment and the monitoring of safety and responding to risk. Concerns about record keeping and governance, including clinical governance showed the service was not well led. Patients did not have a named GP and for patients who had long term conditions there were very few personalised care plans as the provider had just commenced developing them. For patients with long term health conditions there was evidence from QOF that the needs were not met or managed. For example, the practice had achieved managing the health care of 88% patients identified with hypertension, 86% patients with asthma and just under 91% of patients with diabetes.

Structured annual reviews were not always undertaken to check that patients’ health and care needs were being met as there was no planned programme to identify and provide them. For example there were no dedicated clinics for patients with diabetes, cardiovascular or respiratory problems. There was no practice nurse to lead in the delivery of on-going care and treatment for patients with long-term conditions. The practice did not have a robust recall system for patients’ long- term conditions to have monitoring checks. When medication and health checks were carried out patient’s records and test results were not processed and reviewed in a timely way. Therefore there was a risk that there was a delay in patients’ receiving the care and support they required.

Updated 11 June 2015

The practice is rated as inadequate for the care of families, children and young people. There were risks to patients’ safety and a lack of evidence to show the service was safe and well led in all population groups.

Immunisation rates were relatively low for a number of the standard childhood immunisations. For example the practice’s achievement for Meningitis C was just below 77%; Bristol Clinical Commissioning Group (CCG) was just above 94.7%. For the pre-school booster vaccine for five year olds, the practice had achieved 66.7%, Bristol’s CCG average was 88.1%. There were no systems to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk.

Updated 11 June 2015

The practice is rated as inadequate for the care of older people. We saw evidence which showed that basic care and treatment requirements were met. We found that the safety of care for older people was not a priority and there were limited attempts at measuring safe practice. There were risks to patients’ safety and a lack of evidence to show the service was safe and well led in all population groups.

The care of older people was not managed in a holistic way. Little attempt had been made to respond to older people’s needs and access for those with poor mobility or who were housebound was limited. Services for older people were reactive, and there was a limited attempt to engage this patient group to improve the service.

Patients over the age of 75 years did not have a named GP. Influenza vaccinations were provided on an ad hoc basis as there was no planned approach to patients care in this age group. There was a lack of care plans for older people preventing hospital admission.

Updated 11 June 2015

The practice is rated as inadequate for the care of working-age people (including those recently retired and students). The age profile of patients at the practice is mainly those of working age or recently retired. There were risks to patients’ safety and little evidence to show the service was well led in all population groups.

There were some extended opening hours for patients. Patients were provided with appointments up to 6pm four days per week. There was no an online appointment booking system and repeat prescription and appointments could only be booked by telephone or attending the practice.

Updated 11 June 2015

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia). The practice did not carry out advanced care planning for patients with dementia. Information about support groups was made available in the practice for patients with mental health needs. There were risks to patients’ safety and a lack of evidence to show the service was safe and well led in all population groups.

Updated 11 June 2015

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable. There were risks to patients’ safety and a lack of evidence to show the service was safe and well led in all population groups. The practice did not hold a register of patients living in vulnerable circumstances. There was no system to identify or monitor patients who were in vulnerable circumstances that they had received an annual health check.

Staff knew how to recognise signs of abuse in vulnerable adults and children and aware of their responsibilities regarding information sharing and how to contact relevant agencies out of normal working hours.