GP practice closed after CQC inspection

Published: 22 September 2016 Page last updated: 12 May 2022

A south London GP practice has had its registration cancelled after the Care Quality Commission published findings after an inspection in July. It was rated as Inadequate overall.

The practice was also rated as Inadequate for being Safe, Effective and Well-led. It Required Improvement for being Caring and Responsive.

CQC inspectors carried out the announced comprehensive inspection at Dr David Zigmond’s Southwark practice on 5 July 2016 and as a result applied to magistrates to cancel the provider’s registration a few days later - on the basis that there was a serious risk to people’s life, health or well-being.

Dr David Zigmond was part of Southwark Clinical Commissioning Group (CCG) and served approximately 1,420 patients. The practice population had a high proportion of male patients and lower proportion of female patients compared to the national average. There were a higher number of patients of working age and over the age of 75 when compared nationally.

Regulation breaches found by CQC inspectors included:

  • Lack of emergency equipment
  • Staff did not adequately assess patient consent and capacity
  • The methods for prescribing patient medication were unsafe
  • The practice’s procedures around child and adult safeguarding did not ensure that vulnerable people were kept safe
  • The practice did not comply with a number of current medical guidelines and best practice

Other key findings of the inspection team found that there was no oxygen or defibrillator on the premises. Staff at the practice said that there had been two instances where patients had collapsed – but nobody working there had completed basic life support training in the previous 12 months. Staff had also not received fire safety training within the last year and the fire alarm was broken.

Systems around medicines management and treatment of patients with long term conditions or mental health concerns were inadequate. There was no effective system in place to ensure that patients were called for reviews and treatment provided often did not reflect current best practice. This was reflected in the practice’s poor performance in a number or clinical areas relative to other practices nationally and locally.

There were inadequate systems in place to safeguard people against abuse or harm and a number of staff had no DBS certificates.

Staff were not clear about reporting incidents, near misses and concerns. CQC identified several instances where significant events were not acted upon in accordance with practice policy.

While patients were positive about staff and said they were treated with compassion and dignity, there was no evidence of patient or staff feedback being used to drive improvement. Patients did say 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. However, the practice only had a female nurse on site once a month and only provided nursing services twice a week between 9.30am and 12.30pm.

Ursula Gallagher, Deputy Chief Inspector of General Practice in CQC’s London region said: “Whilst we absolutely appreciate how important continuity, kindness and compassion are for patients and carers, many additional things are required to ensure that patients are actually receiving the high quality care they have a right to expect. Unfortunately in this case we found that many of these elements were either absent or inadequate requiring us to take the action we did.”

CQC has worked closely with NHS England to make sure patients have access to other GPs in the area.


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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.