25 September 2017
During a routine inspection
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