Archived: Dr Amir Mir Also known as Cornwallis surgery

Updated 24 September 2015

Dr Amir Mir provides general medical services to approximately 2,300 registered patients. The practice delivers services to a slightly lower number of patients who are aged 65 years and over, when compared with the national average. Data available to the Care Quality Commission (CQC) shows the number of registered patients suffering income deprivation is higher than the national average. Dr Amir Mir had been subject to an investigation and a subsequent hearing by the General Medical Council (GMC) in February 2015. Interim conditions were imposed by the GMC upon Dr Amir Mir’s registration. Those conditions included a requirement for Dr Mir to confine his medical practice to general practice within the Cornwallis Surgery and for all work to be closely supervised by a named GP located within the same site.

The practice is located in large, purpose built premises which house a number of other primary care service providers. Care and treatment is usually delivered by one GP and one locum GP, who provides services to the practice on one day each week. However, at the time of our inspection, the registered GP was subject to an unplanned absence from the practice. The practice had made arrangements for an additional locum GP to cover this period of absence. The practice had employed one practice nurse until the week prior to our inspection. The nurse had been employed on a part-time basis, so nurse cover had not been available within the practice every day. At the time of our inspection there were no practice nurses employed by the practice. There were informal arrangements in place for a neighbouring GP practice within the same building, to provide some nurse appointments on the practice’s behalf. Patients requiring urgent appointments with a nurse were also being sent to the walk-in centre on the ground floor of the same building. The GPs are supported by a business and financial manager who has recently assumed the role of practice manager. There is a small team of administration and reception staff.

The practice is open from 8.00am to 5.00pm on weekdays. Extended hours consultations are usually available one evening per week from 5:30pm until 6.30pm. However, those extended hours consultations were not available to patients during the absence of the registered GP. After 5pm each day the practice closes and patients who telephone the practice receive pre-recorded instructions to use out of hours services. Due to the shared location of the practice, patients are able to enter the reception area of the practice after 5pm but no staff are available after this time.

The practice had been subject to a previous inspection visit on 17 July 2014. At this visit we found the provider had not notified the Care Quality Commission of their change of name or ensured that patients were protected from the risk of abuse, because the provider had failed to undertake criminal record checks for staff. In March 2015 we followed up on our inspection of 17 July 2014 to check that action had been taken to meet the required standards. The provider had formally notified the CQC of their change of name and we saw evidence of criminal record checks for members of staff via the Disclosure and Barring Service (DBS).

Our inspection visit on 14 July 2015 was unannounced due to concerns raised about the practice. Due to further concerns raised at this visit, another unannounced visit was made to the practice on 23 July 2015.

Services are provided from:

Cornwallis Surgery, Station Plaza Health Centre, Station Approach, Hastings, East Sussex, TN34 1BA.

The practice has opted out of providing out of hours services to its own patients and uses the services of a local out of hours service.

Updated 24 September 2015

Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection of Dr Amir Mir on 14 and 23 July 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective, caring and responsive services and for being well led. It was also 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 whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

We found the provider to be in breach of of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The regulations breached were:

• Regulation 12 (1) (2) (a) (b) (c) (d) (f) (g) (h): Safe Care and Treatment
• Regulation 13 (1) (2): Safeguarding service users from abuse and improper treatment
• Regulation 18 (1) (2) (a): Staffing
• Regulation 19 (1) (a) (b) (2) (a) (3) (a): Fit and proper persons employed
• Regulation 17 (1) (2) (a) (b) (c) (d) (e) (f): Good governance

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, the review of patients’ laboratory tests results were subject to significant delays and appropriate recruitment checks on staff had not been undertaken prior to their employment.
• Patients were unable to access care when they needed to due to insufficient staffing levels and inconsistent arrangements for ensuring access to GP and nurse appointments.
• Medicines were not appropriately managed within the practice. There were no supplies of emergency medicines and the temperature of a refrigerator used to store vaccinations was not routinely monitored.
• There was a lack safeguarding arrangements in place to protect vulnerable adults and children. The GP lead for safeguarding within the practice was absent and no alternative arrangements had been implemented. Staff had not received training in the safeguarding of vulnerable adults and children.
• Staff had not been supported in accessing training to meet their needs. For example staff had not received training in health and safety, infection control or chaperoning.
• Staff had not received appropriate supervision or appraisal. There were no team meetings held within the practice.
• There was a lack of openness and transparency within the management team and a lack of reporting of incidents, near misses and concerns. There was no evidence of learning and communication with staff.
• The practice did not have a patient participation group. They had not gathered feedback from patients to implement changes to service provision and promote continuous improvement.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
• Patients with long term conditions had received appropriate review of their care and treatment.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

If the provider had continued to be registered, the areas where the provider must have made improvements are:

• Implement processes to ensure the timely review of all patient laboratory test results.
• Ensure staffing levels and appointment access arrangements enable patients to access care to meet their urgent and routine healthcare needs.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure a supply of emergency medicines is available within the practice and that medicines are appropriately stored and monitored.
• Ensure arrangements are in place to safeguard vulnerable adults and children from abuse.
• Implement systems to ensure all clinicians are kept up to date with national guidance and guidelines.
• Ensure audits of practice are undertaken, including completed clinical audit cycles.
• Ensure clear processes for the recording, review and learning from significant events and incidents.
• Ensure there are formal governance arrangements in place, including systems for assessing and monitoring risks and the quality of the service provision.
• Ensure assessment of risk is undertaken and monitoring recommendations are implemented, in order to reduce the risk of exposure of staff and patients to legionella bacteria.
• Ensure staff undertake training to meet their needs, including training in the safeguarding of vulnerable adults and children, health and safety, chaperoning and infection control processes.
• Provide opportunities for staff to receive regular supervision and appraisal.
• Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements
• Ensure the practice establishes a patient participation group and implements processes and procedures to gather feedback from patients.

If the provider had continued to be registered, the areas where the provider should have made improvements are:

• Develop an action plan to ensure findings from the infection control audit are reviewed and actions completed.
• Ensure protocols for repeat prescribing and the initiation of new prescriptions are in line with national guidance.

On the basis of the concerns identified at this inspection we took action to enforce urgent suspension of the provider’s registration, under Section 31 of the Health and Social Care Act 2008. This enforcement action is subject to appeal by the provider. Following our inspection visit, Dr Amir Mir submitted an application to cancel their registration and this application was accepted. We subsequently received an application from another provider to provide services from the same location. This application was accepted and patients previously registered with Dr Amir Mir are able to access care from the new provider. The service provided at Cornwallis Surgery will be put into special measures. The new provider will be responsible for ensuring that improvements are made.

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

Updated 24 September 2015

The practice is rated as inadequate for the care of patients with long term conditions. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Structured annual reviews had been undertaken by the practice nurse to check that the health and care needs of patients with long term conditions were being met. However, it was unclear what arrangements had been put in place to ensure the ongoing care and review of patients with long term conditions in the absence of a practice nurse. Therefore patients with long term conditions may not have been able to access the care they needed in order to prevent deterioration of their condition.

Updated 24 September 2015

The practice is rated as inadequate for the care of families, children and young patients. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Access to appointments was restrictive for families, children and young people. The practice closed at 5pm each day. The practice usually had extended access appointments from 5.30pm until 6.30pm on one evening each week, although this was not available at the time of our inspection due to the unplanned absence of the registered GP. The practice offered a full range of immunisations for children. However, vaccination services within the practice were not available at the time of our inspection due to the absence of a practice nurse. The practice did not have clear arrangements in place to continue to provide vaccination services for children at the time of inspection.

Updated 24 September 2015

The practice is rated as inadequate for the care of older patients. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice worked closely with a number of local residential and care homes to provide care and support to the older patients. For example, the GP provided visits to local residential care homes to provide flu vaccinations and to undertake reviews of patients with long term conditions.

Updated 24 September 2015

The practice is rated as inadequate for the care of working age patients (including those recently retired and students). The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Access to appointments was restrictive for patients of working age. The practice closed at 5pm each day. The practice usually had extended access appointments from 5.30pm until 6.30pm on one evening each week, although this was not available at the time of our inspection due to the unplanned absence of the registered GP.

Updated 24 September 2015

The practice is rated as inadequate for the care of patients experiencing poor mental health (including people with dementia). The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice maintained a register of vulnerable patients which was regularly reviewed. The register included patients experiencing poor mental health. The practice held multidisciplinary team meetings monthly to discuss the needs of patients with poor mental health.

Updated 24 September 2015

The practice is rated as inadequate for the care of patients whose circumstances may make them vulnerable. The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice maintained a register of vulnerable patients which was regularly reviewed. The register included housebound patients and patients receiving end of life care. The practice held multidisciplinary team meetings monthly to discuss the needs of complex patients. For example, the practice worked with palliative care nurses to support those patients with end of life care needs.