Archived: Dr Kim Cheung

This practice is rated as Inadequate. (This practice was inspected in December 2014 and rated as good overall. We then carried out a further comprehensive inspection in January 2018 where the practice was rated as inadequate and placed into special measures. As a result of the findings at this inspection, we issued the provider with a warning notice to make improvements. We then carried out a focused follow up inspection in June 2018 to check that the improvements had been made. This inspection was not rated.)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Dr Kim Cheung on 14 August 2018. We carried out a comprehensive inspection as part of our inspection programme under Section 60 of the Health and Social Care Act 2008 to follow up on risks identified from our previous inspections. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• Some areas of improvements were noted since the January 2018 and June 2018 inspections. However, we found multiple repeat breaches of regulation that had not been adequately dealt with, since the lead GP had been absent from the practice from May 2018.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Unverified quality and outcome framework data showed the practice had positive clinical outcomes for their patients and had improved their level of exception reporting since the previous inspection. However, some improvements were required in relation to vulnerable adults and for those suffering with poor mental health.
• Overall, we found that the leadership lacked the capacity and strategy to provide effective arrangements and systems, which led to governance, policies and procedural failures.
• The practice had carried out all environmental risk assessments to ensure they safeguarded patients and staff from harm. For example, we found there was an appropriate fire risk assessment, health and safety assessment, Legionella assessment and a Control of Substances Hazardous to Health assessment (COSHH).
• The practice was clean and tidy and aspects of infection prevention control. An infection control audit was carried out during the inspection after this was pointed out to the practice.
• Patient safety and medicine alerts were reviewed and shared amongst the clinical team however they were not actioned and we found patients at risk. Since the previous inspection the practice has reviewed patients at risks and put processes in place to mitigate harm.
• The system for monitoring patients taking high risk medicines still required strengthening. We reviewed 16 patients being prescribed Warfarin, eight patients did not have relevant blood test results recorded on their notes but had been prescribed Warfarin. Since the inspection the practice told us that they had reviewed patients taking high risk medicines and found only one patient that had not received a blood test. We were advised that this patient had been contacted and a blood test had been requested. The practice had also informed us that they had contacted the local clinical commissioning group to opt out of prescribing high-risk medicines.
• The practice was not equipped to deal with medical emergencies. Since the previous inspections the practice had ordered an oxygen canister that was unsuitable for medical emergencies.
• The practice had reviewed the emergency medicines they stocked however two medicines recommended by guidance, were not being stocked and there was no risk assessment to account for this decision. Since the inspection the practice had purchased the two recommended medicines.
• We found staff had completed most of the required training to meet the needs of their patients. The practice outlined that staff were required to carry out annual information governance training which they had not completed. We also found that the lead GP’s basic life support training had not been updated. Since the inspection the lead GP had organised the appropriate training.
• During this inspection we found the lead GP had completed the relevant safeguarding adults training. The GP had also carried out online level 3 safeguarding children’s training yet we were unsure that the face to face training had been carried out at level three as required.
• Staff files had been organised however there was no evidence that the lead GP or practice nurse had medical indemnity insurance or correct immunisations. Since the inspection the practice have provided evidence of both.
• Practice policies had been updated and were now unique to the practice.
• Clinicians knew how to identify and manage patients with severe infections, for example, sepsis and we saw information aids to enable staff to deal with the emergencies. However, the practice did not have appropriate equipment on site to respond to these infections. Since the inspection the practice had mitigated risks by ordering the equipment required.
• The practice had identified 0.7% of its practice list as carers by highlighting them during registration and during clinical consultations.
• Staff were aware of local protocols and had adequate knowledge to safeguard vulnerable adults and children. Staff had carried out safeguarding training however we were unable to distinguish whether the lead GP had received face to face safeguarding children’s training at level three.
• Electrical devices had been portable appliance testing and medical equipment had been calibrated since the January 2018 inspection.
• We saw staff treated patients with kindness and respect, and maintained patient dignity and information confidentiality.
• Patients spoke positively about the care they received from the practice, which was in line with the friends and family test and the national GP patient survey data published in July 2018.
• There was evidence of actions taken to support good antimicrobial stewardship. The practice was one of the lowest antibiotic prescribers within their CCG.

Shortly after the inspection and due to the level of risk to patients that we identified, we wrote formally to the provider to establish what immediate action they proposed to take to reduce that risk and to enable us to consider the most appropriate type of enforcement action we would take, if any, to protect patients. The provider replied to us with a satisfactory action plan for improvement in the short term and this meant that more serious enforcement action was not required as the risks were being managed.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Establish effective process to identify carers to enable support and advice to be offered to those that require it.
• Strengthen processes to monitor staff training needs.
• Carry out an annual infection control audit in line with published guidance.
• Establish an organised process to store all relevant documents including staff immunisations and indemnity certificates.
• Improve performance in relation to the number of new cancer cases treated resulting from a two week wait referral.
• Continue to improve the exception reporting rate in relation to patients suffering from poor mental health.

This service was placed in special measures in March 2018. A further inspection was made in June 2018, and the practice remained in special measures. Insufficient improvements have been made such that there remains a rating of inadequate for safe and well-led. As a result of the current inspection, the practice remains in special measures. We are now taking further action against the provider, Dr Kim Cheung, in line with our enforcement policy and we will report further on this when it is completed.

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

Dr Kim Cheungs practice was previously inspected in December 2014 and received a rating of good overall. In January 2018 we carried out a comprehensive inspection where the practice was rated as inadequate overall. We found the practice was inadequate for providing safe and well-led services. As a result, we issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.

We carried out an announced focused inspection at Dr Kim Cheung on 5 June 2018. The focused inspection was to review whether the provider had made improvements and was compliant with the warning notice. We also looked at the governance arrangements and the leadership of the practice. The inspection was carried out part of our inspection programme under Section 60 of the Health and Social Care Act 2008.

At this inspection we found:

• Some areas of improvements highlighted in the January 2018 inspection had been acted upon however there were multiple areas that previously required improving that the provider had not resolved.
• The practice had carried out all environmental risk assessments to ensure they safeguarded patients and staff from harm. For example, we found there was an appropriate fire risk assessment, health and safety assessment, Legionella assessment and a Control of Substances Hazardous to Health assessment (COSHH).
• The practice was clean and tidy and aspects of infection prevention control had been audited since the January 2018 inspection.
• The practice had improved the process to ensure patient safety and medicine alerts were reviewed, acted on and shared amongst the clinical team.
• The system for monitoring patients taking high risk medicines still required strengthening.
• The practice was still not equipped to deal with medical emergencies as we found they did not have access to oxygen although it had been ordered three days prior to the inspection. The practice had revised their emergency medicines stock however they had not considered all relevant and appropriate medicines for which there were no risk assessments.
• Staff had completed most of their training to meet the needs of their patients and responsibilities. Yet staff had not carried out information governance training which the practice had outlined needed to be completed annually.
• The sample of practice policies we reviewed during the inspection had been updated and were unique to the practice.
• Staff were aware of local protocols and had adequate knowledge to safeguard vulnerable adults and children. There were now updated safeguarding protocols in place for staff to be able to refer to.
• We found that the safeguarding lead had not completed the appropriate training to carry out the role.
• Electrical devices and medical equipment had been portable appliance tested and calibrated in April 2018.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure care and treatment is provided in a safe way to patients.

The practice had not made effective improvements to comply with the warning notice and we also found that there was a lack of leadership due to the absence of the provider, who had not made sufficient governance arrangements in their absence. The practice remains in special measures and we are considering taking enforcement action.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice