Archived: Dr Khin Thanda Also known as Avenham Lane Practice

Updated 23 November 2017

Dr Khin Thanda’s practice is a single handed GP practice and is based in a purpose built facility, Avenham Lane Health Centre in Avenham Lane, Preston, PR1 3RG. The building also accommodates community health services. The practice is part of Greater Preston Clinical Commissioning Group and all services are delivered under a General Medical Services (GMS) contract.

Dr Khin Thanda is supported by one male long-term locum GP who has been with the practice for more than six years. The GPs work 2.5 days each and are supported by an advanced nurse practitioner (ANP) who works for 20 hours each week. The practice has three administrative and reception staff who are led by the part -time practice manager.

The surgery is open to patients between 8.30am and 6pm on weekdays and appointments are offered from 9am to 11.30am and 4pm to 6pm. Appointments on Thursday afternoons are for emergencies only. Patients can telephone the surgery from 8am in the morning and between 6pm and 6.30pm when telephone access to the practice is diverted to a mobile telephone number. When the practice is closed patients are advised to contact NHS 111. Out of hours service is provided by GotoDoc Ltd., based at Preston hospital.

Patients can book appointments in person, via the telephone or online through the national Patient Access service. The practice provides telephone consultations, pre-bookable consultations, urgent consultations and home visits.

The practice has car parking immediately outside the building, with clearly marked disabled spaces. There are accessible toilets in the community health centre which patients visiting the practice can use. All patient facilities are located at ground floor level. The practice has a reception and waiting area, two GP consulting rooms and a nurse treatment room with further administrative areas.

The practice provides services to 3425 registered patients. Data shows the practice population is made up of a higher proportion of patients aged under 18 years compared to the national average (24% compared to 21%) and fewer patients aged 65 years and over than nationally (5% compared to 17%).

Information published by Public Health England rates the level of deprivation within the practice population group as one on a scale of one to 10. Level one represents the highest levels of deprivation and level 10 the lowest. There are 49% of patients with a long-standing health condition; lower than the national average of 53%. The practice has a higher percentage of unemployed patients compared with the national average; 18% compared with 4%.

Updated 23 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Khin Thanda, also known as Avenham Lane Practice, on 7 December 2016. The practice was rated as inadequate for providing safe, effective, caring, responsive and well-led services and was placed into special measures for a period of six months. We also issued two warning notices in respect of safe care and treatment, and good governance. The full comprehensive report on the inspection on 7 December 2017 can be found by selecting the ‘reports’ link for Dr Khin Thanda on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 25 September 2017. At this most recent inspection we saw that the practice had taken steps to address some of the concerns identified at our previous inspection, however, some significant concerns remained and we also identified new concerns related to the clinical care of patients and the safe storage of refrigerated vaccines.

Overall the practice is still rated as inadequate.

Our key findings were as follows:

• We saw evidence that knowledge of and reference to national guidelines and guidance for patients’ clinical care and treatment by the principal GP was lacking. Medicines were on several occasions, prescribed inappropriately.
• There was evidence that patient treatment records had insufficient details to give assurance that an adequate clinical assessment of the patient had been made and there was a lack of recording of the patient medical history and clinical signs. We saw that referrals to other services lacked detail and that there was no system in place to follow up patients who did not book appointments with services after referral.
• There was limited evidence generally of quality improvement. There was an improved system for managing significant events, however actions taken as a result of events were not reviewed. A new audit programme had been introduced although it was in its early stages and documentation of audit required improvement.
• There was little documentation of clinical discussion and, although we saw that patient safety alerts had been addressed, there was no documentation of this and the principal GP was unaware of recent alerts.
• Systems to safeguard patients from abuse had improved since our last inspection although one practice policy to safeguard children was out of date. This was updated following our inspection.
• Records of temperatures made for refrigerated vaccines recorded temperatures over recommended levels for up to five days and the surgery had not responded appropriately to ensure patient safety. The use of loose prescription forms in the practice was not monitored.
• The practice had improved the cleanliness and hygiene of the premises since our last inspection and had introduced measures to ensure that the appropriate levels of infection prevention and control (IPC) were maintained although we saw a lack of risk assessment to assure patient and staff safety.
• The practice had failed to address the low results identified by our last inspection for the Quality and Outcomes Framework (QOF) which measured the review of patients with long-term health conditions. Results for this continued to fall (based on unvalidated figures). Low results for patient national cancer screening programmes had not been addressed and the identification of patients who were also carers was still poor.
• The practice had improved the process for working with other community and health and social care staff although we saw no evidence of care planning for vulnerable patients.
• The practice had failed to engage with patients to seek feedback on service development and delivery. As at our last inspection, there was no patient participation group and little attempt to seek patient feedback on areas for improvement. The practice still did not have a website and the practice social media page had very little information for patients. The practice had failed to address the high numbers of patients attending the local A&E department and patient concerns regarding access that were evidenced in the latest national GP patient survey.
• The practice complaints process had been improved since our last inspection and both written and verbal complaints were recorded. Patient comment cards that we received praised staff for being caring and helpful and for treating them professionally.
• We did not find that the leadership of the practice was sufficient to ensure high quality care for patients or good governance of the practice.

The areas where the provider must make improvements are:

• 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.

In addition the provider should:

• Enable sufficient records to be kept for clinical discussion in meetings to allow learning to be shared.
• Improve the system for documenting quality improvement work in the practice to ensure that learning outcomes can be clearly identified and acted upon.
• Continue to improve the identification of patients who are also carers.

This service was placed in special measures in December 2016. Insufficient improvements have been made and further concerns have been identified. There remains a rating of inadequate for providing safe, effective and well led services. Therefore we are taking 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 with the Care Quality Commission.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• Systems to review patients with long-term health conditions were lacking; there was a high non-attendance of patients who were called to the practice for a health review and no comprehensive plan in place to address this.
• Data from the Quality and Outcomes Framework (QOF) showed that practice performance overall was lower than local and national averages and was not improving. Unverified data from 2016/17 indicated that the practice had achieved 74% of points available (414.48 out of 559 points) compared to 81% in 2015/16 and 85% in 2014/15.
• The practice advanced nurse practitioner was trained in the management of patient long-term conditions and specialised in the care and treatment of diabetic patients.

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• From the sample of documented examples we reviewed we found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. Staff knew how to report safeguarding concerns.

• Immunisation rates were relatively high for all standard childhood immunisations, however, the management of refrigerated vaccines was inadequate. The practice had not addressed the high temperatures recorded for two fridges in the practice or ensured that the stored vaccines were safe.
• Clinical staff demonstrated how children and young people were treated in an age-appropriate way and were recognised as individuals although the principal GP demonstrated a lack of understanding of best practice (Fraser) guidelines.
• The practice’s uptake for the cervical screening programme was 78%, which was comparable to the CCG and the national average of 81%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• Consultation notes on patient records we viewed had insufficient details to give assurance that an adequate assessment of the patient had been made and care and treatment did not always follow best practice guidelines. There was little evidence that follow-up arrangements for patients with health problems were made.
• Attendance for national cancer screening programmes was low. Attendance for breast screening was 33% compared to 65% locally and 73% nationally and attendance for bowel screening was 35% compared to 58% locally and nationally. The practice had no plan in place to address this.
• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
• The practice held multidisciplinary meetings on a monthly basis where patients with complex needs were discussed to ensure they were being cared for appropriately.
• Where older patients had complex needs, the practice shared summary care records with local care services including the out of hours service.

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• The practice did not have a website but patients could access online services through the national Patient Access system.
• At the time of our inspection, there were no extended hours appointments offered. We were told this was due to start in October 2017 through a sharing agreement with local practices. These appointments had not been advertised to patients and surgery opening hours on the NHS Choices website were incorrect.
• QOF results in relation to interventions and support for patients who were smokers were lower than local and national averages.
• Attendance rates at the local A&E department were high and the practice had not addressed this.
• Telephone appointments with clinicians were available in addition to face-to-face appointments.

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• Performance for mental health related indicators was lower than average. For example, the percentage of patients with mental health problems who had an agreed comprehensive care plan documented in their record within the preceding 12 months was 46%, compared to the local and national average of 89% (unvalidated results for 2016/17 were 58%).

• The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face to face meeting in the previous 12 months was 67%, compared to the local average of 86% and national average of 84% (unvalidated results for 2016/17 were 70%).
• Clinical staff were trained in the Mental Capacity Act (MCA) and also Deprivation of Liberty Safeguards (DoLS). However, we found that the principal GP demonstrated only a basic understanding of some aspects of the MCA.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice maintained a register of patients experiencing poor mental health.

Updated 23 November 2017

The provider was rated as requires improvement for providing caring and responsive services and inadequate for providing safe, effective and well-led services. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• We saw evidence that three patients were prescribed a particular medicine for its sedative effect and not for its intended use.
• There was a high number of patients who failed to make hospital appointments following referral by the practice and no plan in place to address this.
• The practice held a register of patients living in vulnerable circumstances including those with a learning disability and those requiring more GP care such as palliative patients.
• The practice offered longer appointments for patients with a learning disability.
• The practice told us that it produced care plans for vulnerable patients but was unable to evidence this.
• The practice worked with the local nearby centre for homeless people, registering these patients to ensure that they could receive appropriate care and treatment.
• A local service worked with the practice to provide care and treatment for patients experiencing drug misuse.