Archived: Dr Alan Samuel Muir Grasse

Updated 8 May 2015

Dr Alan Samuel Muir Grasse (known as West End Lane Medical Practice) is located in Camden, North London and has a patient list of approximately 1,400 (one of the smallest in Camden). The practice holds a General Medical Service (GMS) contract with NHS England. This is a contract between general practices and NHS England for delivering primary care services to local communities. The practice has opted out of providing out-of-hours services to their own patients.

Twenty two percent of patients are aged 65 or older and 12% are under 18 years old. Forty five percent have a long standing health condition and 10% have carer responsibilities.

The services provided include child health care, ante and post natal care, immunisations and management of long term conditions. The staff team comprises one senior GP (male), four GP locums (one male, three female), practice manager and two part time administrative staff.

The practice is registered to provide the following regulated activities which we inspected: Diagnostic and screening procedures; Treatment of disease, disorder or injury; Maternity and midwifery services.

Public Health England’s Camden 2014 Health Profile notes that the health of people in Camden is varied compared with the England average. Deprivation is higher than average and about 32.5% (10,800) children live in poverty. Life expectancy for both men and women is higher than the England average. Life expectancy is 12 years lower for men and 10 years lower for women in the most deprived areas of Camden than in the least deprived areas.

Regarding child health, 21.8% of ten year olds are classified as obese (worse than the average for England). Levels of teenage pregnancy, breastfeeding and smoking at time of delivery are better than the England average.

Regarding adult health, in 2012, 13.7% of adults were classified as obese (better than the average for England). The rate of self-harm hospital stays was 86.2, better than the average for England. Rates of sexually transmitted infections and TB are worse than average.

In Camden, strategic improvements in health and wellbeing are led by the borough’s Health & Wellbeing Board; comprised of Camden Council, Camden CCG, Camden Healthwatch and other health stakeholders. Priorities include tackling obesity, providing better health outcomes for families with complex needs and reducing harm caused by alcohol.

Updated 8 May 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Alan Samuel Muir Grasse on 11 December 2014. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, well-led, effective and responsive services. We found the practice to require improvement for providing a caring service.

We also found the practice to be inadequate for providing services for older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

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. For example, at the time of our inspection, the practice did not have sufficient drugs or equipment to be able to deal with medical emergencies. At the time of our inspection, the practice did not have an oxygen cylinder;
• There was insufficient assurance to demonstrate people received effective care and treatment. Patient outcomes were at or below average for the locality in a range of clinical areas including diabetes management, chronic kidney disease and cervical screening;
• The practice had limited formal governance arrangements;
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

The areas where the provider must make improvements are:

• Ensure that there is a clear policy and process to address the needs of patients with long term conditions;
• Undertake a review of patients on chronic disease management registers, triggered by the marked variance between practice and locality QOF performance;
• Introduce a system for monitoring patient outcomes (including use of clinical audits) and take action to improve patient outcomes;
• Undertake a risk assessment of how the practice responds to emergency medical situations;
• Ensure that an oxygen cylinder is on site to be able to deal with medical emergencies;
• Ensure that arrangements are in place to be able to identify and act on patients’ concerns;
• Ensure that all non clinical staff are up to date regarding cardio-pulmonary resuscitation (CPR) training.
• Implement systems for sharing learning from significant events and complaints;
• Undertake a review of cervical screening performance triggered by the marked variance between practice and locality QOF performance (45% of women had a record of a cervical smear test within the last five years compared with the Camden practice average of 75%).

The areas where the provider should make improvement are:

• Formally document multidisciplinary team meetings so that these can be used to monitor and improve patient outcomes as necessary;
• Arrange chaperone training for the practice manager;
• Consider the arrangements for dealing with medical emergencies;
• Ensure that the practice website allows patients to request repeat prescriptions;
• Ensure that it is made clear to all patients how they should access services at all times that the surgery is closed during their contracted hours of 8.00am to 6.30pm.
• Introduce a formal system for listening and acting on staff feedback.

I am placing the service into 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 vary the provider’s registration 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people with long-term conditions. We noted that nationally reported data showed that patient outcomes for conditions such as diabetes, chronic kidney disease and mental health were below Camden practice averages. The relatively small number of patients with a long term conditions meant that single incidents such as an unplanned hospital admission could have a disproportionate impact on overall patient outcome performance. Overall however, there was no evidence of action being taken to improve outcomes for patients with long term conditions. For example, although the practice held a long term condition register and patients had a named GP, patient reviews appeared opportunistic. The senior GP worked with other health care professionals such as district nurses to deliver a multidisciplinary and coordinated package of care although we noted that these meetings were not minuted.

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of families, children and young people. Childhood immunisation rates at twelve months, twenty four months and five years were generally better than the average for Camden practices. However, there was no evidence of systems in place to follow up missed appointments. Patients told us that children and young people were treated in an age-appropriate way and we saw evidence to confirm this such as appointment availability outside of school hours. However, we also noted that the premises were not suited for families, children and young people. The practice entrance was not wheelchair accessible and some corridors were too narrow to manoeuvre a push chair. We also noted that baby changing facilities were not available.

Child immunisation were undertaken by the GPs at the surgery but without access to all equipment to deal with medical emergencies.

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of older people. Care and treatment of older people did not always reflect current evidence-based practice. Nationally reported data showed that outcomes for patients for conditions commonly found in older people were mixed. For example, although all patients diagnosed with dementia had had a review in the preceding 12 months; only 33% of patients aged sixty five and older had received seasonal flu vaccination (compared with a Camden practice average of 77%). Longer appointments and home visits were available for older people when needed and this was acknowledged positively in patient feedback. Staff demonstrated knowledge of consent to care and treatment in line with legislation and guidance (including the Mental Capacity Act 2005).

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of working-age people (including those recently retired and students). The profile of patients at the practice is mainly those of working age, students and the recently retired but the services available did not fully reflect the needs of this group. Although the practice offered extended opening hours until 6.30pm for appointments from Monday to Friday, there were no early opening hours for working people and patients could book appointments on line but not order repeat prescriptions. Health promotion advice was offered on the practice website and throughout the practice. We noted that there was a low take up of health checks and health screening compared to the Camden practice average. For example, only 45% of women had a record of a cervical smear test within the last five years; compared with the respective Camden and England practice averages of 75% and 72%. We noted limited evidence of action being taken to improve this patient outcome.

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia). Only 37% of people experiencing poor mental health had had a cholesterol check within the preceding twelve months and only 45% had had their body mass index recorded. This compared with the respective Camden and England practice averages of 69% and 82%. There was no evidence of action being taken to improve patient outcomes.

There was evidence that the practice had systems in place to support patients presenting with acutely poor mental health and also to signpost patients with less severe symptoms to specialist local voluntary sector organisations. However, we also noted that the practice’s performance on new diagnoses of depression, which had had a review not later than the target 35 days after diagnosis, was below the practice averages for Camden and England.

Updated 8 May 2015

The provider was rated inadequate for the domains of safety, effectiveness, responsiveness and well led; and requires improvement for caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable. The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

Staff were aware of various support groups and voluntary organisations for vulnerable people. They knew how to recognise signs of abuse in vulnerable adults and children. Staff were also aware of their responsibilities regarding information sharing, documenting safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

The practice offered interpreting services in a range of languages including British Sign Language (BSL). We noted that 10% of patients had a caring responsibility.