Archived: East Ham Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at East Ham Medical Centre on 31 May 2016. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because a non-clinical staff member was actioning patients’ laboratory test results that were not reviewed by GPs or clinical staff.
• Systems and processes were not in place to keep patients safe. For example there was no health and safety risk assessment, fire safety risk assessment or guidance for action in the event of a fire.
• The defibrillator did not work and emergency use oxygen cylinders had either expired or were too big to move.
• The practice had not carried out safety testing of non-clinical electrical equipment and clinical equipment had no cleaning schedule in place.
• The practice had a number of policies and procedures to govern activity, but some were missing and others were insufficient or had not been implemented such as recruitment, control of substances hazardous to health (COSHH), chaperoning and induction.
• Staff understood their responsibilities to raise concerns. However, reporting systems had weaknesses and reviews and investigations had not occurred. Patients did not always receive an apology and there was no evidence of learning and communication with staff.
• Staff did not have access to current evidence based guidance or safety alerts and had not been trained to provide them with the skills, knowledge and experience to deliver safe and effective care and treatment.
• The practice had not learned lessons to make improvements following significant events or complaints because the reporting and investigation system was ineffective.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice had no clear leadership and management structure, insufficient leadership knowledge and skill and limited formal governance arrangements.

The partnership that made the provider dissolved on 1 September 2016 and no longer exists. The current provider is in the process of applying to register with the CQC.

At the time of our inspection the provider was found to be in breach of Regulations 12 (Safe care and treatment), 16 Receiving and acting on complaints, 17 (Good governance), 18 (Staffing), and 19 (Fit and proper persons employed) of the Health and Social Care Act (Regulated Activities) Regulations 2014

If the provider was still registered the areas we would have set out the following list of how the provider must make improvements:

• Ensure appropriate staff qualifications, training and support and implement all necessary employment checks for all staff.
• Implement effective systems for receiving and managing complaints and seeking and recording patients consent.
• Establish systems and processes to identify and mitigate risks to patient’s safety including medicines, equipment , infection control and in the event of a medical emergency.
• Implement effective systems and processes to assess, monitor and improve quality.
• Ensure there is leadership knowledge and skill to deliver all improvements.

And the following list of areas where the provider should make improvements:

• Take action to address patient dissatisfaction indicated by the GP patient survey results and seek to improve identification of patients that are carers.
• Make arrangements to ensure appropriate monitoring of prescription pads.
• Improve information on the practice leaflet and review patients’ access to appointments.

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 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.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice