Archived: Dr Win Hlaing Also known as Burma Hill Surgery

When we inspected Dr Win Hlaing on 17 and 19 December 2019, we identified a range of serious concerns and breaches of regulation. Consequently, we issued the provider with a Warning Notice to improve the safe provision of care and treatment which had to be complied with by the end of March 2019. At the same time, we placed conditions upon the registration of the service to ensure the practice provided care and treatment in the safest possible way. As a consequence of our findings we placed the practice into special measures.

The provider sent us an action plan setting out how they would meet both the requirements of the Warning Notice and the conditions imposed. This inspection was carried out on 8 April 2019, the day the practice transferred to a new provider to check that the practice had complied with the warning notice. We also reviewed progress in achieving the action plan to improve safety in providing care and treatment.

We found the practice had achieved compliance with the Warning Notice because, the practice had carried out reviews of patients prescribed medicines for their long term medical condition including:

• Patients receiving repeat prescriptions for hypnotic medicines had been recalled. They had been consulted about their condition and received an appropriate review of the prescribing. In total the practice had identified 19 patients receiving repeat prescriptions for a specific type of sleeping tablet and had reviewed 18 out of 19 patients (the final patient had only just registered with the practice).
• A total of 40 out of 45 patients identified by the practice as being prescribed a medicine to control their thyroid function had received a review and had their usage of the medicine checked appropriately. Of the five not reviewed the practice found four had not received a recent prescription and were likely to have de-registered from the practice and one patient was being followed up because they had not responded to requests to have the appropriate test and review of their care.
• Since the inspection in December 2018, the practice identified a total of 24 patients taking a medicine to control blood clotting and had ensured that 23 had the appropriate annual test and result review to support continued prescribing. The final patient had recently been started on this medicine by a hospital clinician and was known to be a patient who was difficult to engage with and follow up.
• The practice had appropriately reviewed the prescribing of two patients prescribed a medicine to control their mood. Both these patients had previously not received appropriate monitoring of their prescribing.
• The practice had identified a further 37 patients in addition to the 123 patients identified in December’s inspection for whom there was no record of receiving the immunisation to reduce the risk of contracting pneumonia. A campaign had been mounted to call these patient for the immunisation and at the time of this inspection only 56 remained to receive the immunisation. We noted that at least 10 patients had told clinicians currently working at the practice they had received the immunisation in the past. However, administration of the immunisation was not recorded in the patient records.
• The practice could demonstrate that reminders were sent to patients entitled to flu immunisation who had not received the immunisation prior to the December inspection. However, uptake was limited due to the flu ‘season’ coming to an end soon after the last inspection.

In addition to complying with the Warning Notice the practice had also reported compliance with the conditions imposed upon their registration. For example:

• There was a system in place to monitor the prescribing undertaken by the nurse prescriber. We saw an example of a mentoring meeting where prescribing updates were discussed. In addition, the GPs had carried out an audit of 50 cases of the nurse prescribing and found that prescribing had been appropriate in all cases.
• The patient recall system had been improved by use of more appropriate searches for patients requiring follow up and implementation of information technology systems to programme the recall.
• A sample of eight records of review of prescribing were reviewed and in all eight cases the review had been timely and appropriate. Records of the review were detailed clearly in the patient’s records.
• The CQC GP advisor also reviewed a further 10 patient records of consultations undertaken since December 2018 and found all contained appropriate levels of detail that would enable an alternative clinician to identify action taken.
• Governance processes had been enhanced with weekly clinical governance meetings clearly recorded and action reviewed arising from governance decisions. A total of five clinical audits had been carried out to review appropriate prescribing and monitoring of patients either with long term conditions or prescribed high-risk medicines. There were records of the actions taken arising from findings of audit.
• Systems to identify and act upon risk were in place. A total of 17 significant events had been recorded since December 2018 and records showed appropriate learning had been shared and action taken to reduce risk when a significant event was identified. For example, when one example of inappropriate prescribing was identified the practice searched to find other patients prescribed the same medicine and acted to reduce risk.
• Staff reported enhanced and improved involvement in governance and training since December. All staff were invited to take part in the weekly governance meetings.
• Records showed that governance of the process to respond to safety alerts had improved with action recorded to address all safety alerts that were relevant to the practice.

The practice had made significant progress in the three months since the last inspection in December 2018 and risks to patients from previous practice had been reduced.

Due to the change in provider that took place on the day of inspection CQC are unable to further follow up the breaches of regulation identified in the practice of the previous provider.

Because this was a focused inspection we have not updated our ratings and provision of an evidence table is not appropriate.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Dr Win Hlaing (Burma Hills Surgery) on 17 and 19 December 2018, as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor, on the second day of the inspection (19 December 2018) the team included a second CQC inspector.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

The practice is rated as Inadequate overall.

Dr Win Hlaing is registered with the CQC as an individual. However, since February 2018 Dr Win Hlaing has been working with two GPs from a neighbouring practice as GP partners. The practice is also part of a larger GP organisation, Modality Partnership, who are in the process of amending the practice registration. We undertook this inspection because although the practice was rated good overall from an inspection carried out in September 2015 we had concerns arising from a focused inspection undertaken in June 2018. At that time, we found that some of the systems operated did not identify, assess and mitigate risks to the provision of safe care.

At this inspection we found further areas of significant concern. The practice was failing to keep patients safe because:

• Prescribing was not following current national guidelines.
• Appropriate tests were not being undertaken to support safe prescribing.
• Patients with long term conditions were not always receiving safe and appropriate care due to failures to follow up test results that indicated action was needed to improve patient treatment.
• Systems to invite patients in for immunisations and treatment were not operated effectively and patients eligible for immunisations were not always receiving them.
• Staff understanding of legislation covering consent to treatment was inconsistent. Patients were at risk of receiving care they did not consent to or not receiving appropriate care due to their age.
• The practice did not have a comprehensive programme of quality improvement activity and did not consistently review the effectiveness and appropriateness of the care provided.
• The delivery of high quality care was not assured by the leadership, governance and culture of the practice.
• Cancer screening and diagnosis rates were low compared to local and national averages.
• The practice did not have clear systems, practices and processes to keep people safe and safeguarded from harm.
• The overall governance arrangements were ineffective.
• Staff requiring supervision of their prescribing were not receiving such supervision.

However, we also found some positive areas of work within the practice:

• Patient feedback was consistently positive about being treated with care, concern and compassion.
• The appointment system was working well and patients reported no problems in accessing appointments when they needed them.
• Staff said they felt supported to do their job and received regular appraisals.

As a result of this inspection the practice has:

• Had conditions applied to the provider’s registration to reduce the risk to patients receiving care at the practice.
• Been served with a Warning Notice regarding the breach of the Health and Social Care Act 2008, Regulation 12, Safe care and treatment.

I am placing this service in 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 further 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 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.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice