The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Tun Lwin Also known as Prince Regent Lane Medical Centre

Overall: Inadequate read more about inspection ratings

343 Prince Regent Lane, London, E16 3JL (020) 7511 2980

Provided and run by:
Dr Tun Lwin

All Inspections

14 August 2018

During a routine inspection

This practice is rated as Inadequate overall. (Previous rating 31 August 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection at Dr Tun Lwin on 14 August 2018. This inspection was to follow up breaches of regulation 17 and 19 identified at our previous inspection.

Dr Tun Lwin was initially inspected on 9 December 2016. During that comprehensive inspection we identified concerns in respect of safety arrangements including fire safety systems, recruitment checks including Disclosure and Barring Services (DBS) checks for clinical staff and systems to act on safety alerts. In addition, we found that Patient Group Directions (PGDs) intended to allow nurses to administer medicines in line with legislation had not been authorised by a prescriber as required. We issued requirement notices in respect of breaches of regulation 12 (Safe Care and Treatment), 17 (Good Governance) and 19 (Fit and Proper Person Employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was rated as requires improvement for key questions: are services safe and are services well led? This meant that the provider was rated as requires improvement overall.

We undertook a focused follow up inspection on 3 August 2017 to see if these breaches had been addressed. This inspection focused on the two key questions rated as requires improvement at the first inspection: Are services safe? Are services well led? We again identified concerns around systems to ensure the safe recruitment of staff and fire safety. We issued the provider with requirement notices in respect of breaches of regulation 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the inspection of 14 August 2018 we found:

  • Some individuals undertaking clinical work had not been subject to the necessary recruitment checks.
  • Reviews of patient records showed a lack of consistent and clear documentation of interactions with patients and instances where follow up actions were not performed at all or in a timely manner. There was a lack of effective clinical governance arrangements to ensure oversight and completion of clinical tasks.
  • The practice did not have adequate systems in place to respond to medical emergencies and not all medical equipment had been calibrated.
  • Systems and processes in certain areas did not work effectively including arrangements to safeguard patients from abuse, infection control, the monitoring of consent, significant event management, medicines management and the monitoring of cancer referrals.
  • The practice performed well against most clinical targets. However, the practice was not meeting Public Health England targets related to cervical screening and childhood immunisations. We were told that this was related to a lack of nursing time and there were no plans in place to meet these targets.
  • Arrangements for recording consent and acting on concerns around a person’s mental capacity were not clear.
  • Care planning was inconsistent.
  • Complaints were not always responded to in writing in accordance with the practice’s policy.
  • There was minimal evidence of quality improvement activity including audit.
  • Staff involved and treated patients with compassion and kindness but systems around privacy were lacking and the practice had only identified a small proportion of their patient list as having caring responsibilities.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. However, deficiencies in clinical governance hindered the practice’s ability to be responsive to patient needs.
  • Complaints were not dealt with in line with the practice policy and information on how to make a complaint was not easily accessible.
  • There was a limited evidence of continuous learning and improvement within the practice.

The areas where the provider must make improvements are:

  • Ensure that care and treatment of patients is only provided with the consent of the relevant person.
  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The areas where the provider should make improvements are:

  • Consider how best to periodically review patient safety alerts related to contraindicated medicines.
  • Improve systems for safeguarding particularly related to chaperoning and training.
  • Expand quality improvement activity including clinical audit.
  • Improve systems to ensure care plans are drafted where appropriate.
  • Ensure all staff are aware of the practice’s business continuity arrangements.
  • Improve the practice’s complaints system around accessibility and provision of formal responses.

I am placing this service into special measures. Warning notices have been issued in respect of breaches of regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with a two-month deadline to achieve compliance. We will reinspect the service after two months to reassess the provider’s compliance with the relevant regulations. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we may take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This may 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 may move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

3 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 9 December 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 9 December 2016 inspection can be found by selecting the ‘all reports’ link for Dr Tun Lwin on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 3 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 9 December 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as requires improvement.

Our key findings were as follows:

  • Recruitment procedures were out of date, had not been implemented effectively and there were gaps in recruitment checks and other important arrangements for staff such as references checks and clinicians medical indemnity cover.
  • Systems to assess, monitor and improve the quality and safety of the service were variable, such as fire safety signage issues and arrangements to ensure patient confidentiality had not been properly addressed.
  • Appropriate arrangements were in place to identify and mitigate risks to patient’s safety including safety alerts and Patient Group Directions (PGDs) intended to allow nurses to administer medicines in line with legislation
  • There were effective arrangements to identify carers and provide them with appropriate support.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed, and related specified information is available regarding each person employed.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Tun Lwin on 9 December 2016. Overall the practice is rated as requires improvement. Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patients were safeguarded from abuse but there were gaps or weaknesses in arrangements for safety such as fire safety, recruitment checks including DBS checks for clinical staff and following up of safety alerts. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Patient Group Directions (PGDs) intended to allow nurses to administer medicines in line with legislation had been authorised by the practice manager and not a prescriber as required and the first aid kit contents were out of date.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Documentation in areas such as meeting minutes did not always demonstrate effective governance arrangements.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice received feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Implement effective arrangements to identify and mitigate risks to patient’s safety including safety alerts, fire safety, and Patient Group Directions (PGDs) intended to allow nurses to administer medicines in line with legislation
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Assess, monitor and improve the quality and safety of the service including strategy and oversight, management or documentation of complaints and practice meetings, and patient’s removal from the practice register.

In addition the provider should:

  • Review arrangements to identify carers to provide appropriate support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice