Archived: P.A.Patel Surgery

Updated 15 December 2016

P.A.Patel was inspected by CQC in November 2015. The practice was rated as inadequate overall and placed into special measures. Practices placed into special measures receive another comprehensive inspection within six months of the publication of the report so we carried out an announced comprehensive inspection at P.A.Patel Surgery on 25 July 2016 to check whether sufficient improvements had been made to take the practice out of special measures.

P.A.Patel practice is located in a converted house in a residential area of Benfleet, Essex. The practice has a list size of approximately 2400 patients; the practice list was closed at the time of our inspection in line with conditions imposed by CQC following our last inspection.

The practice has a smaller than average population aged 0 to 39 years old and a larger than average population aged 50 years and over.

The staff comprises of a male GP, a practice manager, a practice nurse and a team of receptionists. The practice also uses two regular locum GPs including a female GP to give patients a choice when booking appointments.

The practice is open between 8.30am and 1pm and 2pm and 6.30pm daily, on Tuesdays the practice remains open until 7.30pm. Appointments are available between 9am and 11.20am daily and between 4pm and 6.15pm (7.30pm on Tuesdays) every day apart from Thursdays when there is no afternoon clinic although home visits are available if required.

The practice is a member of the local GP Alliance which offers patients weekend appointments at an alternative location.

When the practice is closed, patients are directed to call 111 to access out of hours services. These services are provided by Integrated Care 24.

Updated 15 December 2016

Letter from the Chief Inspector of General Practice

On 10 November 2015, we carried out a comprehensive announced inspection. We rated the practice as inadequate overall. The practice was rated as inadequate for providing safe, caring and well-led services, requires improvement for providing effective services and good for providing responsive services. As a result of the inadequate rating overall the practice was placed into special measures for six months.

We carried out an announced comprehensive inspection at P.A.Patel Surgery on 25 July 2016 to check whether sufficient improvements had been made to take the practice out of special measures. Overall the practice rating remains inadequate.

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

• We could not be assured that patients were always assessed and reviewed appropriately due to a lack of detail in patient records. A new system had been implemented for identifying and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, the documentation was not always in sufficient detail.
• Data showed patient outcomes were low compared to local and national averages.
• All staff acting as chaperones had received a disclosure and barring service check.
• Although some audits had recently been carried out, there was insufficient evidence to show that they were driving improvements to patient outcomes.
• Data showed patient satisfaction regarding access to services was above local and national averages.
• The practice manager had taken a leadership role and started to implement a more robust governance framework; however it was unclear if there was sufficient clinical leadership to drive improvement in patient outcomes.
• There was no effective system in place to ensure patient safety and medicine alerts were received or actioned.
• Staff understood their responsibilities to safeguard patients from abuse; however not all staff had up to date safeguarding training.
• Risks to patients were assessed and most were well managed, with the exception of risks identified relating to health and safety and infection control.
• Emergency equipment and medicines were available; however some of the emergency medicines were found to be out of date.
• The practice had implemented monthly palliative care meetings to discuss patients receiving end of life care. The practice did not attend multidisciplinary meetings to discuss other patients with complex needs.
• The majority of patients said they were treated with compassion, dignity and respect.
• A complaints toolkit was available to demonstrate how the practice would deal with complaints; however the practice had not received any complaints in the last 12 months. Verbal or informal complaints were not recorded.
• There was a simple staff structure and staff knew their responsibilities; however when some staff were absent, there was no system in place to ensure their duties were covered.

The areas where the provider must make improvements are:

• Record significant events thoroughly to demonstrate that patients affected receive reasonable support and a verbal and written apology.

• Implement an effective system to ensure patient safety and medicines alerts are actioned.

• Ensure that there is effective quality improvement activity in place at the practice to improve patient outcomes.
• Ensure all staff receive up to date and appropriate safeguarding training.
• Ensure a robust system of checks is in place to ensure emergency medicines are in date.
• Ensure all risks identified relating to health and safety and infection control are actioned and managed.
• Ensure clinicians conduct and record patient reviews and assessments in sufficient detail to demonstrate appropriate care and investigations.
• Ensure staff duties are covered when staff are absent.
• Ensure there is sufficient clinical leadership to drive improvement in patient outcomes.
• Ensure verbal and informal complaints are recorded, responded and discussed.

In addition the provider should:

• Work with other health and social care organisations to meet the requirements of patients with complex needs.
• Continue to identify carers and offer these patients additional support.

This service was placed in special measures in January 2016. Insufficient improvements have been made such that 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 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 six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 15 December 2016

The practice is rated as inadequate for the care of people with long-term conditions.

• The practice nurse and the GP shared a role in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Practice performance for long term conditions such as diabetes was below local and national averages. For example, 58% of patients with diabetes, on the register, had their last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less (01/04/2014 to 31/03/2015), this was lower than the CCG average of 72% and the national average of 78%.
• We were not assured that patients were consistently receiving long term condition or medicine reviews. We also could not be assured that all patients presenting with acute complaints were being adequately assessed.
• Longer appointments and home visits were available when needed.
• All these patients had a named GP. However not all these patients had a structured annual review to check their health and medicines needs were being met.

Updated 15 December 2016

The practice is rated as inadequate for the care of families, children and young people.

• Immunisation rates for the standard childhood immunisations were mixed. For example; 100% of two year olds received the Infant Men C vaccine compared to the local average of 98%. 89% of two year olds received the MMR vaccine compared to the local average of 95%.
• Children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• Some staff had not received an appropriate level of safeguarding training.
• Appointments were available outside of school hours and the premises were suitable for families, children and young people.
• 85% of women aged 25-64 had a record of a cervical screening test being performed in the preceding 5 years (01/04/2014 to 31/03/2015), this was comparable to the CCG average of 88% and a national average of 82%.

Updated 15 December 2016

The practice is rated as inadequate for the care of older people.

• The practice offered personalised care to meet the needs of the older people in its population.
• The practice offered home visits and urgent appointments for those with enhanced needs.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older people were below local and national averages. For example, only 30% of patients with COPD who had a review undertaken including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months (01/04/2014 to 31/03/2015), this was below the CCG average of 88% and the national average of 90%.

Updated 15 December 2016

The practice is rated as inadequate for the care of working-age people (including those recently retired and students).

• The practice aimed to offer accessible and flexible services to meet the needs of the working age population including those recently retired and students.
• The practice did not have a website and had limited online services for their patients.
• There was a range of health promotion advice available in the practice.

Updated 15 December 2016

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia).

• Only 38% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2014 to 31/03/2015, this was below the CCG average of 77% and the national average of 88%.
• The practice had not worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice followed up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had an understanding of how to support patients with mental health needs and dementia.

Updated 15 December 2016

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

• 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.
• The practice worked with other health care professionals in the case management of vulnerable patients when needed.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• 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. Some staff needed to attend safeguarding training courses.