Archived: Dr R M, D R Patel

Updated 12 July 2017

Dr RM and DR Patel’s practice is located at Dartmouth Medical Centre, a purpose built building in West Bromwich, an area of the West Midlands, with a branch surgery at Central Clinic in Tipton, West Midlands. We did not inspect the branch surgery as part of this inspection. The practice has a General Medical Services contract (GMS) with NHS England. A GMS contract ensures practices provide essential services for people who are sick as well as, for example, chronic disease management and end of life care and is a nationally agreed contract. The practice also provides some enhanced services such as childhood vaccination and immunisation schemes.

The practice provides primary medical services to approximately 3,200 patients in the local community. The practice was led by three GP Partners, but one of the GP partners recently retired, and notification had been submitted to the CQC to advise them of a change to partnership. The current GP partners (1 male and 1 female) have the support of two practice nurses and three regular locums (2 male and 1 female). The non-clinical team consists of administrative and reception staff and a practice manager.

Based on data available from Public Health England, the levels of deprivation in the area served by the practice are below the national average and ranked at two out of ten, with ten being the least deprived.

The practice is open to patients between 8am and 6.30pm on Monday, Tuesday, Thursday and Friday and 8am and 1pm on Wednesday. When Dartmouth Medical Centre is closed on Wednesday afternoon, patients can access appointments at the branch surgery. Extended hours appointments are available 6.30pm to 8pm on Monday and 9am to 12pm Saturday. Telephone consultations are available if patients requested them; home visits were also available for patients who are unable to attend the surgery. When the practice is closed, primary medical services are provided by Primecare, an out of hours service provider and information about this is available on the practice website.

We had previously inspected the practice in January 2017 where we found that aspects of the services were not safe or suitable for the purpose of carrying on the regulated activities. This focused inspection was based on the registration of the current providers who are the only providers delivering regulated activity at the location Dartmouth Medical Centre. We found that the there are still aspects of the services that are not safe or suitable; however plans were in place for a new provider to offer the regulated activities in the near future.

Updated 12 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr R M and D R Patels practice in Dartmouth Medical Centre on 10 January 2017. Overall the practice is rated as Inadequate.

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

• The practice had lacked capacity and capability in clinical leadership to support either safe, high quality clinical care or to implement the improvement indicated via the vision and strategy.
• Staff understood their responsibilities to raise concerns, incidents and near misses and there was a system in place for reporting and recording significant events.
• Arrangements were in place to safeguard children and vulnerable adults from abuse, and local requirements and policies were accessible to all staff. The GP partner was unable to confirm there was a system in place to identify children and young people who have had a high number of A&E attendances. However, since the inspection we have received evidence to confirm that the practice had a system in place to ensure all children were followed up following frequent attendances at A&E.
• The practice had introduced a system to ensure safety alerts including those received from the Medicines and Healthcare Products Regulatory Agency (MHRA) alerts were actioned. However, on speaking with the GP we were unable to confirm these were acted on appropriately.
• Clinical staff did not always assess patients’ needs and deliver effective care in line with current evidence based guidance. For example, 10 medical records we reviewed did not contain an accurate, complete and contemporaneous record in respect of each patient’s consultation. This included an inadequate record of the care and treatment provided.
• Some of the patient records we reviewed showed care and treatment was not delivered in line with recognised professional standards and guidelines, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
• The practice had an electronic system to store patient records and to show the actions which had been agreed to meet patients' care, treatment and monitoring needs. However key members of the clinical team where unable to use this system meaning that care could be compromised. We also found that even where handwritten notes of the consultations had been made these were not reliably added to the patient records. The consultations that had been attached to the electronic system, were difficult to read or illegible. This increased the risk that information about treatments provided may be overlooked.
• Non clinical staff were adding medicines to patients’ records on behalf of the GP partners. No checks were made by clinically trained staff to ensure medicines had been added correctly or that contraindications between medicines had been identified.

• Some audits had been carried out however we saw no evidence that clinical audits were driving improvement in performance and patient outcomes.

• Patients said they found it easy to make an appointment with a GP and that there was continuity of care, with urgent appointments available the same day.

• Cleaning schedules were in place for the building, however there was no up to date schedule available for the cleaning of medical equipment after use.
• Patients we spoke with on the day, 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

However there were areas of practice where the provider must make improvements:

• Implement a systematic approach to care delivery and improvement underpinned by appropriate clinical leadership and managerial capacity.
• Ensure an accurate and contemporaneous record is kept for each patient, with detailed information in relation to their assessment of needs, planning and delivery of care and there is an effective system in place for ensuring patient records are completed by staff with the necessary skills and understanding.
• Ensure effective systems are in place for care and treatment to be delivered in line with national guidance and best practice guidelines. This is important to ensure patients receive appropriate care and reviews.
• Ensure effective governance, including assurance and auditing processes that drive improvement in the quality and safety of the services is in place. This includes both clinical and non-clinical governance arrangements that identifies, assesses and manages risks to patient safety; as well as monitors the quality of services provided.
• The provider must have processes and procedures to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. This includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005, how to assess mental capacity and an understanding of the Gillick competency test.
• Maintain records to evidence the receipt of and actions taken in respect of patient safety information received from the Medicines and Healthcare products Regulatory Agency (MHRA) alerts to ensure prescribing remains safe.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures. Services placed in special measures will be inspected again within six months.

Due to the nature of the concerns identified on this inspection urgent action has been taken, to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 conditions have been imposed on the registration of the provider in respect of the following regulated activity: Treatment of Disease, Disorder or Injury from Dartmouth Medical Centre, 1 Richard Street, West Bromwich, B70 9JL West Midlands and Central Clinic, Horseley Road, Tipton, DY4 7NB West Midlands. Conditions on the provider’s registration have been imposed due to the seriousness of the lack of contemporaneous records available and took effect from 13 January 2017.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed further urgent enforcement action could be taken. 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.

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 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• Some of the patient records we reviewed showed care and treatment was not delivered in line with recognised professional standards and guidelines, including National Institute for Health and Care Excellence (NICE) best practice guidelines. NICE guidelines were available on the GP computer system, but the GP could not recall the last NICE guidance that had been issued and therefore we could gain no assurances that NICE guidelines were being followed.
• Due to the absence of poor records, we were unable to confirm that essential reviews had been completed.
• The practice offered a range of services to support the diagnosis and management of patients with long term conditions and nursing staff had lead roles in chronic disease management. The latest QOF data (2015/16) showed 78% of diabetic patients had received their flu vaccination; this was comparable to the national target of 76%.
• Longer appointments and home visits were available when needed.
• Patients with long term conditions had a named GP and an annual review to check their health and medicines needs were being met. Patients at risk of hospital admission were identified as a priority. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. For example the practice worked with a community diabetes specialist nurse to support patients with complex diabetic needs.

Updated 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• There were systems in place to identify and follow up children living in disadvantaged circumstances, including policies, procedures and contact numbers to support and guide staff should they have any safeguarding concerns about children, but the GP partner was unaware of a system in place to identify children and young people who had a high number of A&E attendances. However since the inspection we have received further evidence to confirm the practice had a system in place to monitor this.
• Appointments were available outside of school hours for children and baby changing facilities were available.
• We saw positive examples of joint working with midwives and health visitors. The midwife held an antenatal clinic every week at the practice.
• The GP did not show an understanding of the Gillick competency test and their duties in fulfilling it. The Gillick competency test is used to help assess whether a child under the age of 16 has the maturity to make their own decisions and to understand the implications of those decisions.
• Childhood immunisation rates for under two year olds were above 90% which was in line with the national standards. Immunisation rates for five year olds ranged from 94% to 100% compared to the national average of 88% to 94%.
• The practice’s uptake for the cervical screening programme was 90% which was higher than the national average of 82%. The practice sent out appointments in various languages to encourage patients to attend. There was no explanation for the high exception reporting rate.

Updated 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. This included vaccinations for those patients who were unable to attend the practice.
• Data provided by the practice showed seven patients on the palliative care register and six had received an annual medication review.
• The practice held a register for unplanned admissions, data provided by the practice currently showed 76 patients on this register. The register was reviewed every six months by the GP. Patients who were discharged from hospital were reviewed to establish the reason for admission and medication changes were completed by the GP. However, on reviewing one patient record we found that changes from a hospital letter had been added by a non- clinical member of staff.
• The practice worked with multi-disciplinary teams so patients’ conditions could be safely managed in the community. Multidisciplinary team meetings were held every two months, however due to the lack of contemporaneous records co-ordination of care was not effective.

Updated 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was offered online services as well as a full range of health promotion and screening that reflected the needs for this age group.
• The practice provided a health check to all new patients and carried out routine NHS health checks for patients aged 40-74 years.
• The practice offered extended hours to suit the working age population, with late evening appointments available once a week and Saturday morning appointments.
• Results from the national GP survey in July 2016 showed 85% of patients were satisfied with the surgery’s opening hours which was higher than the local average of 77% and the national average of 76%.

Updated 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• The latest published data from the Quality and Outcomes Framework (QOF) of 2015/16 showed 75% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the national average of 78%. Exception reporting rate was 12.5% which was higher than the national average of 7%.
• The practice had told patients experiencing poor mental health how to access various support groups and voluntary organisations.
• Data provided by the practice showed 36 patients on the mental health register and the latest published QOF data (2015/16) showed 90% of patients had received a comprehensive care plan in the past 12 months; this was higher than the national average of 78%.
• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia; however the GP was unaware of how to assess mental capacity and had no knowledge of deprivation of liberty safeguarding (DoLS).
• A counsellor offers support to patients with mental health needs once a week at the main practice site (Dartmouth Medical Centre).

Updated 26 April 2017

The practice is rated as inadequate for safe, effective and well led services; this affects all six population groups.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• The practice offered longer appointments for patients with a learning disability. Data provided by the practice showed 13 patients aged over 18 years of age were on the learning disability register and 12 had received their annual health checks. The practice sent regular appointments to patients to encourage them to attend their appointments.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations and signposted patients to relevant services available.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
• The practice had installed a call bell at the front entrance to alert staff if a patient required assistance to access the premises.
• The practice’s computer system alerted GPs if a patient was also a carer. There were 56 patients on the practices register for carers; this was 1.7% of the practice list. Data provided by the practice showed 44 carers had received their flu vaccination.