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This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations. Ratings Overall rating for this service Inadequate ––– Are services safe? Inadequate ––– Are services effective? Inadequate ––– Are services caring? Requires improvement ––– Are services responsive to people’s needs? Requires improvement ––– Are services well-led? Inadequate ––– Dr Dr Sharif Sharif Hossain Hossain Quality Report Lister Primary Care Centre London Southwark SE15 5LJ Tel: 02030498360 Website: N/A Date of inspection visit: 8 August 2017 Date of publication: 09/11/2017 1 Dr Sharif Hossain Quality Report 09/11/2017

Dr Sharif Hossain NewApproachComprehensive Report … · 2019. 7. 11. · Thisreportdescribesourjudgementofthequalityofcareatthisservice.Itisbasedonacombinationofwhatwefound …

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  • This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

    Ratings

    Overall rating for this service Inadequate –––Are services safe? Inadequate –––

    Are services effective? Inadequate –––

    Are services caring? Requires improvement –––

    Are services responsive to people’s needs? Requires improvement –––

    Are services well-led? Inadequate –––

    DrDr SharifSharif HossainHossainQuality Report

    Lister Primary Care CentreLondonSouthwarkSE15 5LJTel: 02030498360Website: N/A

    Date of inspection visit: 8 August 2017Date of publication: 09/11/2017

    1 Dr Sharif Hossain Quality Report 09/11/2017

  • Contents

    PageSummary of this inspectionOverall summary 2

    The five questions we ask and what we found 5

    The six population groups and what we found 8

    What people who use the service say 12

    Detailed findings from this inspectionOur inspection team 13

    Background to Dr Sharif Hossain 13

    Why we carried out this inspection 13

    How we carried out this inspection 13

    Detailed findings 15

    Overall summaryLetter from the Chief Inspector of GeneralPractice

    We carried out an announced comprehensive inspectionof Dr Sharif Hossain on 22 September 2016. The overallrating for the practice was inadequate and the servicewas placed in special measures for a period of sixmonths. The full comprehensive report from theinspection undertaken on 22 September 2016 can befound by selecting the ‘all reports’ link for Dr SharifHossain on our website at www.cqc.org.uk.

    As a result of our findings from this inspection CQC issueda requirement notice for the identified breaches ofRegulations 12, 18 and 19 and a warning notice forRegulation 17 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. Specifically wefound concerns related to: the processes for identificationand management of significant events, the practice’ssafeguarding processes, management of risks associatedwith infection control and fire safety, not all staff hadreceived an internal appraisal within the previous 12months, not all staff had completed the requisite

    essential training, the practice were not undertaking aregular check of staffs’ professional registrations andrecruitment checks did not ensure patients were keptsafe.

    We also issued a requirement notice in respect ofbreaches in regulation 13 of CQC (Registration)Regulations 2009: the practice did not have adequateindemnity insurance in place for their nursing staff.

    This inspection was undertaken within six months of thepublication of the last inspection report as the practicewas rated as inadequate and placed in special measures.This was an announced comprehensive inspectioncompleted on 8 August 2017. Overall the practice is stillrated as inadequate.

    The concerns identified on the day of the inspectionincluded:

    • There was no effective system in place for thedissemination of patient safety alerts and no evidencethat all alerts were reviewed and acted upon.

    • There was no effective system in place for recordingand storing controlled medicines.

    Summary of findings

    2 Dr Sharif Hossain Quality Report 09/11/2017

  • • There was no effective system in place for ensuringthat pathology results were reviewed actioned andarchived into patient records.

    • There was no effective system in place to monitorpatients who were referred for urgent assessment anddiagnosis.

    • There was no effective system in place for recallingpatients with long term conditions who requiredregular reviews or for those who required periodicreviews of their medication including those on highrisk medicines.

    • The practice was not following current clinicalguidance and best practice.

    • The practice did not keep an accurate, complete andcontemporaneous account or record of the careprovided for all patients.

    • There was a failure to assess and take action inresponse to various risks including those related to firesafety.

    Other key findings across all the areas we inspected wereas follows:

    • There were inconsistent accounts of the system inplace for recording significant events and not allevents had been documented. The practice policy forsignificant events was from another practice.

    • Systems for mitigating risks associated with infectioncontrol were not clear or effective.

    • Staff did not have the all the requisite training skillsand knowledge to deliver effective care and treatment.For example some staff did not have a record of childsafeguarding training and there was no evidence thatclinical updates had been completed for all staff thatadministered immunisations and took samples forcervical screening.

    • Results from the national GP patient survey indicatedpatients were treated with compassion, dignity andrespect and were involved in their care and decisionsabout their treatment. However, both feedback fromstaff on the day and patient survey data indicated thatsome patients were unhappy with the attitude of thereception team.

    • Information about how to complain was available. Wefound that some of the health promotion informationin the reception area was out of date.

    • Some patients we spoke with said they found itdifficult to make an appointment at a convenient timeor with their preferred GP. Urgent appointments wereavailable the same day.

    • The practice had good facilities and was well equippedto treat patients and meet their needs.

    • There was an absence of clear leadership in key areas.For example the management of patient safety alerts.Although staff told us they felt supported bymanagement, we were told that staff had only recentlybeen given contracts of employment with legal termsand conditions. We were told that the practice PPGwas not currently active.

    • The provider was aware of the requirements of theduty of candour.

    Had the provider’s registration not been cancelled, wewould have set out the following list of ‘musts’ for theiraction:

    • Ensure the care and treatment of patients isappropriate, meets their needs and reflects theirpreferences

    • Ensure care and treatment is provided in a safe wayto patients

    • Establish effective systems and processes to ensuregood governance in accordance with thefundamental standards of care

    • Ensure persons employed in the provision of theregulated activity receive the appropriate support,training, professional development, supervision andappraisal necessary to enable them to carry out theduties.

    • Ensure recruitment procedures are established andoperated effectively to ensure only fit and properpersons are employed.

    We made a successful application to CamberwellMagistrate’s Court on 10 August 2017 to urgently cancelthe provider’s registration under section 30 of The Healthand Social Care Act 2008 on the basis that there wereseveral breaches of the 2014 Regulations whichpresented serious risks to people's life, health orwell-being. The provider was referred to the appropriateprofessional organisations and a caretaker organisationtook over the management of the practice.

    Professor Steve Field CBE FRCP FFPH FRCGP

    Summary of findings

    3 Dr Sharif Hossain Quality Report 09/11/2017

  • Chief Inspector of General Practice

    Summary of findings

    4 Dr Sharif Hossain Quality Report 09/11/2017

  • The five questions we ask and what we foundWe always ask the following five questions of services.

    Are services safe?The practice is rated as inadequate for providing safe services.

    • The process used to report significant events was not effective.The practice did not have its own policy for reporting significantevents and we found that not all events had been reported andnot all staff were clear on the process for documenting events.

    • There was no effective system for distributing and acting uponpatient safety alerts.

    • Patients were at risk of harm because there were weaknesses inthe processes around safeguarding, recruitment, infectioncontrol, the medicine management, and risk managementmeasures designed to mitigate risks associated with fire. Forexample not all staff had received safeguarding training andthere was little evidence of engagement with the local healthvisitor. There was no register to monitor the use of controlleddrugs and we found controlled medicines were not securelystored. Not all clinical staff had received a DBS check.

    • The practice had systems in place to respond to a clinicalemergency.

    Inadequate –––

    Are services effective?The practice is rated as inadequate for providing effective services.

    • Although data from the Quality and Outcomes Frameworkshowed most patient outcomes were comparable to thenational average, reviews of patient records raised questionsregarding the accuracy of this data. Review of records showedthat care and treatment were not delivered in accordance withevidence based guidance. For example we found instances ofpatients on high risk medicines who were not being reviewed inaccordance with current clinical guidance and best practice.

    • There was no evidence of a programme to improve the qualityof patient care.

    • There was an absence of clinical updates for staff administeringimmunisations and taking cervical screening samples and notall staff had completed essential training includingsafeguarding and basic life support training.

    • There was limited evidence of effective working with otherhealth care agencies. For example we did not see any evidence

    Inadequate –––

    Summary of findings

    5 Dr Sharif Hossain Quality Report 09/11/2017

  • that individual patients were discussed during the most recentpalliative care and safeguarding team meetings. Thesemeetings had exposed potential inaccuracies in the practice’spalliative care and safeguarding registers.

    Are services caring?The practice is rated as requires improvement for providing caringservices.

    • Care planning for patients was limited to those with palliativecare needs. Practice staff had attended course on care planningrecommended by the RCGP with a view to ensure that staffwere able to provide effective care plans for those who requiredthem.

    • Some patients provided negative feedback in the patientsurvey, comment cards and during discussions with patients onthe day of the inspection about the attitude of reception staff.On the day of the inspection we saw staff treated patients withkindness and respect, and maintained patient and informationconfidentiality. Most patient feedback stated that clinical staffwere caring and compassionate.

    • Some information about local health and social care servicesavailable for patients in the reception area was outdated andthe practice had no website where information about patientservices could be accessed.

    Requires improvement –––

    Are services responsive to people’s needs?The practice is rated as requires improvement for providingresponsive services.

    • Feedback from patients indicated that some patients haddifficulty accessing appointments generally, appointments withtheir preferred clinician and that waiting times were long.Urgent same day appointments were available.

    • Deficiencies in care planning and mechanisms to identify andmonitor those with long term conditions limited the practice’scapacity to effectively respond to the needs of all patients.

    • The practice did not have a hearing loop but translationservices were available for patients who required them.

    • Information about how to complain was available.

    Requires improvement –––

    Are services well-led?The practice is rated as inadequate for being well-led.

    • The practice lacked a clear vision and strategy.

    Inadequate –––

    Summary of findings

    6 Dr Sharif Hossain Quality Report 09/11/2017

  • • There was a lack of clear leadership in the practice in key areas.There were gaps in the practice’s governance framework whichexposed patients to risk of harm. For example there was noclear system to manage patient safety alerts and no system inplace for monitoring urgent diagnostic referrals.

    • Staff had only recently been provided with employmentcontracts that were legal after the provider was prompted to doby an external organisation. This was despite staff raising theirconcerns with the provider and practice management.Therefore although the lead GP allowed staff to voice theirconcerns it was evident that these were not always listened toor acted upon.

    • Training was lacking for staff and it was evident that thepractice had no internal mechanism to independently identifytheir own training needs.

    • The provider was aware of the requirements of the duty ofcandour.

    • The practice patient participation group had not been activesince our last inspection.

    • There was no evidence of continuous learning or improvementand no systems which encouraged quality improvement.

    Summary of findings

    7 Dr Sharif Hossain Quality Report 09/11/2017

  • The six population groups and what we foundWe always inspect the quality of care for these six population groups.

    Older peopleThe practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • Though staff were able to recognise the signs of abuse in olderpatients and knew how to escalate any concerns although wenoted that none of the nursing staff had any safeguardingtraining on file.

    • The practice offered home visits and urgent appointments forthose with enhanced needs and staff provided older vulnerablepatients with their personal telephone number but there wasno policy around remote advice no evidence of staff beingtrained to provide advice remotely.

    • The systems around the management of palliative care patientsindicated that patients who required end of life care were notreferred at an early stage to local palliative care services.Discussions with the local palliative care teams did notdemonstrate discussion of specific patients with palliative careneeds. We were told that the latest meeting with the palliativecare team had resulted in the practice reviewing their palliativecare register and identifying five further patients who requiredend of life support but had not been referred.

    • Staff at the practice had only recently begun completing careplans for patients but this was limited to those will palliativecare needs.

    • Health promotional advice in area was available in thereception area but we saw that some of this was out of date.

    Inadequate –––

    People with long term conditionsThe practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • Reviews of the patient record system raised serious concernsabout the practice’s ability to identify those patients with longterm conditions and questions around the quality and efficacyof the care provided. For example there were instances wherepatients were not correctly coded on the system limiting the

    Inadequate –––

    Summary of findings

    8 Dr Sharif Hossain Quality Report 09/11/2017

  • practice’s ability to identify and provide the required care tothose with chronic or long term illnesses. We saw patients whowere not receiving regular tests and assessments required toensure effective management of their condition; includingpatients on high risk medicines.

    • Data indicators designed to measure the practice’smanagement of patients with long term conditions were mostlyin line with local and national averages. However the review ofrecords called into to question the accuracy of this data. Forexample there were instances of diagnostic assessments beingrecorded on the clinical system without any evidence of testshaving been completed in secondary care. We also foundinstances where patients were noted as requiring medicine toenable them to manage their condition safely. In severalinstances we found that despite this medicine having not beenissued for prolonged periods of time, clinicians had placedentries on the clinical system noting that patients had goodcompliance.

    • Care planning was limited for patients with long termconditions. This had been identified by The Royal College ofGeneral Practitioners (RCGP) as an area where cliniciansrequired additional training. Clinicians had completed one ofthree recommended courses.

    • There were emergency processes for patients with long-termconditions who experienced a sudden deterioration in health.

    • All these patients had a named GP.• There was limited evidence of effective multidisciplinary

    working.

    Families, children and young peopleThe practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • We were told that there were systems to identify and follow upchildren living in disadvantaged circumstances and who wereat risk however we did not see any examples of this.

    • Immunisation rates were relatively high for all standardchildhood immunisations.

    • Patients told us, on the day of inspection, that children andyoung people were treated in an age-appropriate way and wererecognised as individuals.

    Inadequate –––

    Summary of findings

    9 Dr Sharif Hossain Quality Report 09/11/2017

  • • Appointments were available outside of school hours. Wefound the female toilets where the baby changing facilities werelocated were dirty.

    • There was limited evidence of working with health visitors. Wewere told that the practice provided ante-natal, post-natal andchild health surveillance clinics.

    • The practice had emergency processes for acutely ill childrenand young people and for acute pregnancy complications.

    Working age people (including those recently retired andstudents)The practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • The practice offered extended opening hours and telephoneconsultations. However some patient feedback indicated thataccess to appointments was an issue and that appointmentswere often not at convenient times and not with their preferredclinician.

    • The practice did not have a website therefore there was nomechanism for the practice to provide online health promotionand screening information. Some of the literature in the waitingarea was also out of date.

    Inadequate –––

    People whose circumstances may make them vulnerableThe practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • The practice held a register of patients living in vulnerablecircumstances including those with a learning disability.However issues identified with coding of patient records andrecent reviews of patient records after multidisciplinarymeetings suggested that this may not have been accurate ornot used effectively.

    • Homeless people were able to register at the practice.• The practice offered longer appointments for patients with a

    learning disability.• There was limited evidence that the practice regularly worked

    with other health care professionals in the case management ofvulnerable patients.

    Inadequate –––

    Summary of findings

    10 Dr Sharif Hossain Quality Report 09/11/2017

  • • The practice had information available for vulnerable patientsabout how to access various support groups and voluntaryorganisations though some of this information in the waitingarea was several years old.

    • Staff interviewed knew how to recognise signs of abuse inchildren, young people and adults whose circumstances maymake them vulnerable. They were aware of theirresponsibilities regarding information sharing, documentationof safeguarding concerns and how to contact relevant agenciesin normal working hours and out of hours. However, we saw noevidence of any safeguarding referrals and there was noevidence of safeguarding training for some staff.

    People experiencing poor mental health (including peoplewith dementia)The practice is rated as inadequate for providing safe, effective andwell-led services and requires improvement for the provision ofcaring and responsive services leading to the practice being rated asinadequate overall. The issues identified impact on the careprovided to this population group.

    • 78% of patients diagnosed with dementia had their carereviewed in a face to face meeting in the last 12 months, whichis comparable to the national average of 84%. Other mentalhealth indicators were higher than local and national averages.However anomalies from a records review raised uncertaintyabout the accuracy of this data and whether care planning hadbeen put in place.

    • Records indicated that the practice’s system for monitoringrepeat prescribing including for patients receiving medicines formental health needs was ineffective and did not ensurepatients received their medicine or ensure that regular reviewswere undertaken for those on high risk medicines.

    • There was little evidence of multi-disciplinary working in thecase management of patients experiencing poor mental health,including those living with dementia.

    • Some of the information in the practice waiting area availablefor patients experiencing poor mental health about how theycould access various support groups and voluntaryorganisations was out of date. The practice had no websitewhich enabled patients to access information about localsupport services.

    Inadequate –––

    Summary of findings

    11 Dr Sharif Hossain Quality Report 09/11/2017

  • What people who use the service sayThe national GP patient survey results were published inJuly 2017. The results showed the practice wasperforming in line with local and national averages inmost areas though some scores related to access werelower. Three hundred and sixty six survey forms weredistributed and 93 were returned. This represented 1.8%of the practice’s patient list.

    • 65% of patients described the overall experience ofthis GP practice as good compared with the CCGaverage of 79% and the national average of 85%.

    • 62% of patients described their experience ofmaking an appointment as good compared with theCCG average of 69% and the national average of73%.

    • 65% of patients said they would recommend this GPpractice to someone who has just moved to the localarea compared to the local average of 73% and thenational average of 77%).

    As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection.We received 26 comment cards and 23 of these wereexclusively positive about the standard of care received.Two of the comments cards were again positive aboutthe clinical care received but contained negativefeedback in respect of the service provided by thereception team and the waiting time for appointments.

    We spoke with eight patients. They told us they weresatisfied with the clinical care provided by the practice.Comments highlighted that clinical staff respondedcompassionately when they needed help and providedsupport when required. However six of the patients wespoke with raised concerns about the attitude of thereception team.

    Summary of findings

    12 Dr Sharif Hossain Quality Report 09/11/2017

  • Our inspection teamOur inspection team was led by:

    Our inspection was led by a CQC Lead Inspector. Theteam included a GP specialist adviser and an Expert byExperience.

    Background to Dr SharifHossainDr Sharif Hossain was part of Southwark ClinicalCommissioning Group and served approximately 5000patients. The practice was registered with the CQC for thefollowing regulated activities Diagnostic and screeningprocedures, Family planning, Maternity and midwiferyservices and Treatment of disease, disorder or injury.

    The practice was located within an area ranked within thesecond most deprived decile on the Index of Multipledeprivation. The practice had a slightly higher than averageproportion of working aged patients and a significantlylower proportion of patients aged over 55 compared to thenational average. The practice had almost double the levelof deprivation affecting children and triple the level ofdeprivation affecting older people.

    The practice was run by one GP principal. The practiceteam also included one male salaried GP and two longterm locums who were male and female. The practice hadfour nurses. The practice offered 22 GP sessions per weekwith booked and emergency appointments five days perweek.

    At our last inspection the practice told us that they had a1500 patient increase in the previous 18 months as a resultof increased registration and the absorption of patientsfrom a neighbouring practice which had recently beenclosed.

    The practice was open between 8am and 7pm Monday toFriday, with the exception of Monday when the practiceclosed at 8pm. Dr Sharif Hossain operated from ListerPrimary Care Centre, London, Southwark SE15 5LJ, whichwere purpose built premises rented and maintained byNHS Property Services. The health centre also hosted threeother GP practices as well as other services including thedistrict nursing team and a benefits advisory service. Thepractice was accessible for patients with mobilitydifficulties.

    Practice patients were directed to contact the local out ofhours provider when the surgery was closed.

    The practice operated under a Personal Medical Services(PMS) contract, and was signed up to a number of local andnational enhanced services (enhanced services require anenhanced level of service provision above what is normallyrequired under the core GP contract). These were:extended hours access, facilitating timely diagnosis andsupport for people with dementia, improving patientonline access, learning disabilities, minor surgery, patientparticipation, rotavirus and shingles immunisation,unplanned admissions, NHS health check, smokingcessation, holistic assessments, integrated casemanagement, ambulatory blood pressure monitoring andpopulation health management quality standards.

    The practice was part of the GP Federation ImprovingHealth Limited.

    DrDr SharifSharif HossainHossainDetailed findings

    13 Dr Sharif Hossain Quality Report 09/11/2017

  • Why we carried out thisinspectionWe undertook a comprehensive inspection of Dr SharifHossain on 22 September 2016 under Section 60 of theHealth and Social Care Act 2008 as part of our regulatoryfunctions. The practice was rated as inadequate and thepractice was placed into special measures. The fullcomprehensive report following the inspection onSeptember 2016 can be found by selecting the ‘all reports’link for Dr Sharif Hossain on our website at www.cqc.org.uk.

    We undertook a follow up inspection of Dr Sharif HossainSurgery on 8 August 2017. This inspection was carried outto review in detail the actions taken by the practice toimprove the quality of care and to confirm that the practicehad made changes to ensure compliance with regulatoryrequirements.

    How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations includingThe Royal College of General Practitioners (RCGP) to sharewhat they knew. We carried out an announced visit on 8August 2017. During our visit we:

    • Spoke with a range of staff (GP’s, practice managementand reception and administrative staff) and spoke withpatients who used the service.

    • Observed how patients were being cared for in thereception area

    • Reviewed a sample of the personal care or treatmentrecords of patients.

    • Reviewed comment cards where patients and membersof the public shared their views and experiences of theservice.

    • Looked at information the practice used to deliver careand treatment plans.

    To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

    • Is it safe?

    • Is it effective?

    • Is it caring?

    • Is it responsive to people’s needs?

    • Is it well-led?

    We also looked at how well services were provided forspecific groups of people and what good care lookedlike for them. The population groups are:

    • older people

    • people with long-term conditions

    • families, children and young people

    • working age people (including those recently retiredand students)

    • people whose circumstances may make themvulnerable

    • People experiencing poor mental health (includingpeople living with dementia).

    Please note that when referring to informationthroughout this report, for example any reference to theQuality and Outcomes Framework data, this relates tothe most recent information available to the CQC at thattime.

    Detailed findings

    14 Dr Sharif Hossain Quality Report 09/11/2017

  • Our findingsAt our previous inspection on 22 September 2016, we ratedthe practice as inadequate for providing safe services as:

    • There was no consistent or effective process for themanagement of significant and staff were not aware ofthings that could possibly constitute a significant eventand not all staff were involved in analysis and discussionof significant events.

    • There was no evidence of an effective system formanaging patient safety alerts.

    • Arrangements to safeguard patients from abuse or harmwere insufficient.

    • Risks associated with infection control, staffing andrecruitment, fire, equipment and the management ofprescriptions had not been adequately addressed.

    • One member of staff had not completed basic lifesupport training and the practice’s business continuityplan did not contain emergency contact information forstaff.

    Not all of these issues had been adequately addressedwhen we undertook a follow up inspection on 8 August2017. For instance, not all significant events had beendocumented as per the stated policy and the practicepolicy was from another practice; staff providedinconsistent accounts regarding the management ofpatient safety alerts and there was no evidence of actiontaken in response to patient safety alerts; infection controlconcerns had not been adequately addressed; recruitmentchecks had not been undertaken for all staff working at thepractice; there was no fire safety policy in place; and not allstaff had received safeguarding training and there was noevidence of safeguarding concerns being escalated to thelocal safeguarding team.

    In addition we found that medicines were not beingmanaged safely including in respect of the storage ofcontrolled medicines and the prescribing and monitoringof high risk medicines.

    Safe track record and learning

    At the last inspection we found staff were unaware of howto report significant events, not all staff were involved insignificant event discussion and not all events had beendocumented in line with the practice’s significant event

    protocol. There was also no effective system in place forrecording action taken in response to patient safety alerts.During this inspection we found the practice policy forsignificant events was from a different GP surgery andsignificant event procedures were still not beingconsistently applied. The system in place to ensure actionwas taken in response to patient safety alerts still did notoperate effectively.

    • The practice had drafted a policy covering how to actupon and document action taken in response to patientsafety alerts. However, it was evident from discussionwith staff that this policy was not working in practice. Weasked three members of staff about the process andasked about specific alerts that had recently arisen.There was no documented evidence of action taken inresponse to these alerts, no member of staff couldverbally inform us which patients were involved and allthree members of staff gave inconsistent accounts as tohow safety alerts were managed.

    • The practice’s significant event policy was from adifferent practice located in a neighbouring CCG wherethe interim practice manager also worked. Staff told usthey would inform the lead GP of any incidents andthere was a recording form available on the practice’scomputer system. The incident recording formsupported the recording of notifiable incidents underthe duty of candour. (The duty of candour is a set ofspecific legal requirements that providers of servicesmust follow when things go wrong with care andtreatment).

    • Although we did see evidence of effective reporting,learning and discussion in respect of several significantevents this was not consistently applied. For examplewe were told of an incident involving a patient injury inthe practice and it was evident from discussion withstaff that this was not recorded as per the practice’spolicy.

    Overview of safety systems and processes

    At the previous CQC inspection we found that the systems,processes and practices in place to keep patients safe fromabuse were not effective. For example there was noinformation in the practice’s safeguarding policy on how toescalate concerns to external safeguarding teams, therewas no evidence of any alert which had been raised withthe local safeguarding team and there was limited

    Are services safe?

    Inadequate –––

    15 Dr Sharif Hossain Quality Report 09/11/2017

  • evidence of working with the health visitor team. Duringthis inspection we found that although policies had beenupdated there was still no evidence of the practice havingraised a safeguarding alert and again there were nodocumented minutes from health visitor meetings wherepatients were discussed. In addition we found a number ofstaff did not have a record of safeguarding training.

    • Staff interviewed demonstrated they understood theirresponsibilities regarding safeguarding. Review of boththe training matrix provided prior to the inspection andstaff files on the day of the inspection showed that therewere gaps in safeguarding training. For example thematrix indicated that none of the nursing staff hadreceived safeguarding training. The staff files of twonurses were reviewed and did not contain anysafeguarding training certificates. We asked for evidenceof this training to be provided after our inspection andwere told that this could not be provided until thenursing staff returned from annual leave.

    • Safeguarding policies reflected relevant legislation andlocal requirements. Policies were accessible to all staff.The policies clearly outlined who to contact for furtherguidance if staff had concerns about a patient’s welfare.There was a lead member of staff for safeguarding. Wereviewed one patient record for a child who wasdeemed to be a safeguarding risk. We asked the practiceto provide evidence that this was flagged to the localsafeguarding team but they were unable to do so. Therewas limited evidence of the practice working with thelocal safeguarding team. We saw evidence that thepractice had met with the local safeguarding teamthough there was no evidence that any patients werediscussed. We were told that the practice were in theprocess of reconciling their safeguarding register withthe patients that the health visitor team weremonitoring as the practice had a number of patients ontheir register that the health visitor team were not awareof.

    • A notice in the waiting room advised patients thatchaperones were available if required. All staff whoacted as chaperones were trained for the role and hadreceived a Disclosure and Barring Service (DBS) check.(DBS checks identify whether a person has a criminalrecord or is on an official list of people barred fromworking in roles where they may have contact withchildren or adults who may be vulnerable).

    On our last visit we found that staff and patient toilets werenot cleaned to a satisfactory standard and that staff hadnot received infection control training since 2014. Inaddition there were gaps in policies relating to infectioncontrol and it was unclear from looking at practice policieswho acted as the practice lead in this area. At thisinspection we found that all staff had received training inthe past 12 months. Again, although most areas of thepractice were clean and hygienic, the patient toilets werenot cleaned to a satisfactory standard.

    • We observed the premises to be clean and tidy in mostareas. There were cleaning schedules and monitoringsystems in place. However, we found that toilets weredirty and that the curtains in some clinical rooms hadnot been changed since September 2016. The practicenurse was the infection prevention and control (IPC)clinical lead. There was an IPC protocol and staff hadreceived up to date training. We saw evidence of arecent IPC audit. There were a number of issues thepractice had addressed and several which had beenflagged as needing to be escalated to the buildingowners. We were unable to find any evidence theseconcerns had been escalated.

    During the previous inspection we found the practice hadno system in place to monitor the use of handwrittenprescriptions although a policy for this was provided afterthe inspection. At this inspection we found thearrangements for managing medicines did not alwaysensure that patients were kept safe. Although the practicehad adequate systems for the management of vaccinesand had a full complement of emergency medicines, areview of patient records recently undertaken by the RCGPraised concerns that patients on high risk medicines orthose who required medicines to manage their long termconditions were either not being prescribed the medicinethey required or were not being regularly monitored toensure they could take their medicine safely. Additionallythe practice did not have systems in place for the safestorage and monitoring of controlled medicines.

    • The provider was able to outline the processes forhandling repeat prescriptions including the review ofhigh risk medicines. However during the inspection wewere presented with a summary of an audit of patientrecords undertaken by the RCGP which reviewed 14records of patients with long term conditions selected atrandom. From reviewing the audit and the clinical

    Are services safe?

    Inadequate –––

    16 Dr Sharif Hossain Quality Report 09/11/2017

  • systems we found serious concerns were identified inrespect of each of the 14 records reviewed whichundermined the integrity of the patient record system asa whole. A number of concerns raised doubts about thepractice’s ability to effectively manage patients’prescribed medicines to help manage their long termconditions including those medicines considered highrisk. Concerns stemming from the records included;patients who were documented as having medicationreviews where there was no evidence of any tests beingrequested or stored on the computer and/or no recordof an appointment which corresponded to thedocumented date of review. On several records wefound patients with long term conditions includingdiabetes and hypertension who were prescribedmedication to manage their condition though this hadnot previously been issued for years. For these patientssubsequent reviews had been noted on the systemwhere the patient’s compliance with medicines wasrecorded as being good despite the patients not havingreceived a prescription for several years. One patienthad been prescribed warfarin but there was no evidenceof this having been issued since early 2016.

    • We saw evidence that the practice had undertakenaudits of their prescribing in an effort to reduceantibiotic prescribing and that this had reduced andwas now in line with local averages.

    • Blank prescription forms and pads were securely storedand there were systems to monitor their use.

    • The practice held stocks of controlled drugs (medicinesthat require extra checks and special storage because oftheir potential misuse) but did not have procedures inplace to manage them safely. For example we found asupply of morphine sitting unsecured in the staffreception area. The practice told us that they hadpurchased this medicine as per CQC guidance onemergency medicines in general practice. Howeverthere was no system to record the practice’s supply ofthis medicine. After raising the need for this medicine tobe secure the lead GP attempted to store the medicinein a cupboard in the treatment room labelled“controlled drugs”. The cupboard was locked andinaccessible so the lead GP stored the medicine in anadjacent cupboard. Staff were unable to locate a key for

    the controlled drug cupboard so we were not able toaccess the cupboard to check if other controlledmedicines were onsite though we were told there wereno others.

    At the last visit we found the practice was not undertakingall necessary recruitment checks for staff working at thepractice and there was a lack of medical indemnityinsurance in place for nursing staff.

    At this inspection we reviewed four personnel files andagain found gaps in the recruitment check information thatshould have been gathered prior to employment and forsome staff there had been no checks undertaken at all. Forexample there was no proof of identification, evidence ofsatisfactory conduct in previous employments in the formof references, qualifications, registration with theappropriate professional body, indemnity cover and theappropriate checks through the DBS for the interimpractice manager or for a locum GP. The practice were alsounable to produce evidence of a DBS check for one of thepermanently employed GPs or one of the nursing staff inthe practice and staff confirmed that this had not beencompleted.

    Monitoring risks to patients

    On our last visit we found that the practice did not haveeasy access to the fire risk assessment completed by theproperty managers, there was no evidence that fire drillshad been completed and portable appliance testing hadnot been completed. At this inspection we again found thatthe practice had not paid adequate attention to fire safetyrisks though portable appliance testing had beencompleted:

    • There was a health and safety policy available. Howeverthe practice did not have a specific policy whichoutlined what staff should do in the event of a fire as wewere told by practice staff that this was responsibility ofthe NHS property services. A representative for NHSProperty services confirmed that each practice wererequired to have their own fire safety policy. There wasan up to date fire risk assessment for the whole buildingand the fire alarm was tested weekly by the propertymanagers. Again we were told by NHS property servicesthat each practice was responsible for undertaking itsown fire drills but there was no evidence of any drillhaving been completed. Staff were aware of the staffwho acted as fire marshals and, although there was no

    Are services safe?

    Inadequate –––

    17 Dr Sharif Hossain Quality Report 09/11/2017

  • practice specific fire policy, staff we spoke with knewwhat to do in the event of a fire and there was signage inthe waiting area informing patients of the fireevacuation point.

    • All electrical and clinical equipment was checked andcalibrated to ensure it was safe to use and was in goodworking order.

    • The practice and the building managers had a variety ofother risk assessments to monitor safety of the premisessuch as control of substances hazardous to health andinfection control and legionella (Legionella is a term fora particular bacterium which can contaminate watersystems in buildings).

    • There were arrangements for planning and monitoringthe number of staff and mix of staff needed to meetpatients’ needs.

    Arrangements to deal with emergencies and majorincidents

    At the last inspection we found one member of staff hadnot completed basic life support training within the last 12months. At this inspection we found that the practice hadadequate arrangements to respond to emergencies andmajor incidents.

    • There was an instant messaging system on thecomputers in all the consultation and treatment roomswhich alerted staff to any emergency.

    • All staff received annual basic life support training andthere were emergency medicines available in the areabehind the reception desk.

    • The practice had a defibrillator available on thepremises and oxygen with adult and children’s masks. Afirst aid kit and accident book were available.

    • Emergency medicines were easily accessible to staff in asecure area of the practice and all staff knew of theirlocation. However, we found morphine on theemergency medicines trolley which was not securelystored. All the medicines we checked were in date andstored securely.

    The practice had a comprehensive business continuity planfor major incidents such as power failure or buildingdamage. The plan included emergency contact numbersfor staff.

    Are services safe?

    Inadequate –––

    18 Dr Sharif Hossain Quality Report 09/11/2017

  • Our findingsAt our previous inspection on 22 September 2016, we ratedthe practice as requires improvement for providingeffective services as:

    • Not all staff were receiving regular appraisals.• Not all staff had completed the required essential

    training in accordance with current legislation andguidance.

    In addition to the breaches of regulation we recommendedthat the practice:

    • Introduce care planning for patients where this isrequired.

    • Continue to work to improve outcomes for diabeticpatients.

    At this inspection we found again not all staff hadcompleted the required training, there was again noevidence of quality improvement work. Though some careplanning had been introduced and data sources indicatedimproved outcomes for diabetic patients; irregularities inpatient records created uncertainty as to the validity of thisdata and therefore it was unclear if patients were receivingthe care and treatment they required. There was also nofailsafe system in place to ensure results stemming fromurgent referrals were received from secondary care.Evidence indicated the practice system for managingpathology results was ineffective and did not ensure resultswere being reviewed in a timely manner.

    Effective needs assessment

    From reviewing patient records it was evident thatclinicians working within the practice were not providingcare in accordance with current evidence based guidanceand standards, including National Institute for Health andCare Excellence (NICE) best practice guidelines. This wasparticularly apparent in respect of monitoring patients onhigh risk medicines.

    • Reviews of patients’ records highlighted a lack ofcompliance with current evidence based guidance. Forexample the RCGP had prepared an audit of patients,two weeks prior to our inspection, who had beenprescribed medication for high blood pressure, which

    carries risk of kidney damage, had not received anyblood tests to check kidney function within the last 12months. Some patients had not received a blood testwithin the last five years.

    • Patients prescribed high risk drugs such as lithium,methotrexate and warfarin were also not beingmonitored appropriately.

    • We were told the practice had appointed a pharmacistto review the treatment of 900 diabetic patients toensure that their care and treatment were optimised.Reviews undertaken of diabetic patients by the RCGPshowed that care and treatment was not optimised andin some instances patients had not been reviewed orreceived their prescribed medication for years. Noaction had been taken by the practice in response to thefindings.

    Management, monitoring and improving outcomes forpeople

    The practice used the information collected for the Qualityand Outcomes Framework (QOF) and performance againstnational screening programmes to monitor outcomes forpatients. (QOF is a system intended to improve the qualityof general practice and reward good practice). The mostrecent published results were 96% of the total number ofpoints available compared with the clinical commissioninggroup (CCG) average of 94% and national average of95%.The practice’s exception reporting rate was 2.8%compared to the local average of 6.7% and the nationalaverage of 9.8% (Exception reporting is the removal ofpatients from QOF calculations where, for example, thepatients are unable to attend a review meeting or certainmedicines cannot be prescribed because of side effects).

    At the last inspection we recommended that the practicetake action to improve outcomes for diabetic patients.From reviewing the QOF indicators it appeared as thoughaction had been taken and improvements made. Howevera review, of patient records raised questions as to whetherdiagnostic reviews and treatments required under QOF hadactually occurred. Each of the records reviewed containedanomalies which raised questions about the validity ofassessments undertaken. For example there were recordswith: diagnostic assessments but no corresponding patientappointments; test results with no evidence that externalassessments had been undertaken; and details oftreatment provided to patients who were deceased.Additionally there were a number of instances where

    Are services effective?(for example, treatment is effective)

    Inadequate –––

    19 Dr Sharif Hossain Quality Report 09/11/2017

  • patients’ conditions were not correctly coded on thesystem which raised questions regarding the accuracy ofthe practice’s long term condition registers and indicatedthe practice was not aware of all patients with chronicconditions. This limited the practice’s ability to offerappropriate treatment to those with chronic diseases.

    The practice was an outlier in respect of the number ofpatients with atrial fibrillation who met particulardiagnostic criteria who were treated with anti-coagulationdrug therapy. The practice achieved 73% for this indicatorcompared with 86% in the CCG and 87% nationally. Thepractice had not exception reported any patientscompared with 11% in the CCG and 10% nationally. Thiswas discussed with the practice and we were advised thatthe absence of exception reporting meant that the figureswere comparable.

    The practice had higher rates of exception reporting forpatients with cancer; 33% compared to 20% in the CCG and25%. We were not provided with any explanation for thehigher than average exception reporting for this condition.

    The practice was prescribing almost double the number ofantibacterial medicines compared with the CCG and wasabout one third higher that the rate nationally. The practicehad undertaken an audit with CCG of co-moxicla,Cephalosporin’s, Quinolones. As at January 2017 thepractice was comparable to the local and national averagefor their prescribing of these medicines.

    This practice was not an outlier for any other QOF (or othernational) clinical targets according to the official data. Datafrom 2015/16 showed:

    • Performance for diabetes related indicators was similarto the CCG and national averages. For example thepercentage of patients who had well controlled bloodsugar was 68% compared with the CCG average of 70%and the national average of 78%. The practice’s rate ofexception reporting for this indicator was 4% comparedwith the local average of 7% and the national average of13%. The percentage of patients who had controlledblood pressure was 78% compared to the local averageof 75% and the national average of 78%. The rate ofexception reporting for this indicator 2% compared withthe local average of 6% and the national average of 9%.

    • Performance for mental health related indicators washigher than the CCG and national averages. For examplethe percentage of patients with complex mental health

    problems who had an agreed care plan in their noteswas 97% compared with 87% locally and 89 nationally.The rate of exception reporting for this indicator was 3%compared with 5% in the CCG and 13% nationally. Thepercentage of patients with complex mental healthproblems who had their alcohol consumption recordedin their notes was 100% compared with the CCG averageof 86% and the national average of 89%. The practicehad exception reported no patients compared with 4%in the CCG and 10% nationally.

    There was no evidence of quality improvement includingclinical audit:

    • There had been two clinical audits commenced in thelast two years, both of these were completed auditsrelated to prescribing targets. Although both auditsshowed a reduction in prescribing to a level closer to theCCG targets neither audit was designed to improve thequality of clinical care. We were also shown a documentthat referred to vitamin B 12 deficiencies; this again didnot demonstrate any quality improvement. The practicehad also reviewed their urgent referrals and found thatall referrals were appropriate.

    Effective staffing

    Evidence reviewed on the day of the inspection did notshow that staff had the skills and knowledge to delivereffective care and treatment.

    • The practice had an induction programme for all newlyappointed staff. This covered such topics assafeguarding, infection prevention and control, firesafety, health and safety and confidentiality.

    • Role-specific training was present for staff but much ofthis appeared to be out of date. For example all of theclinical update training on file for the member of nursingstaff we reviewed was from late 2013 or early 2014. TheGPs in the practice were enrolled in clinical updatecourses to improve care planning. We were told thatthey had attended one of three training sessions.

    • We did not find up to date training for staffadministering vaccines and no evidence of cervicalscreening training or updates for the nurse whose filewe reviewed.

    • Though there was evidence of appraisals on file for staffit, was evident that the practice was not using these as acollaborative tool to support staff development andwell-being. The appraisals reviewed made reference to

    Are services effective?(for example, treatment is effective)

    Inadequate –––

    20 Dr Sharif Hossain Quality Report 09/11/2017

  • the fact that staff were not receiving statutory holidayentitlement or pension contributions. We were also toldby a member of the PPG that they had been involved inthe staff appraisal process.

    • Not all staff had received essential training thatincluded: safeguarding, basic life support andinformation governance. We asked the practice toprovide training certificates for training that was notpresent after our inspection. We did not receive anyadditional training evidence after our inspection.

    Coordinating patient care and information sharing

    It was evident that clinicians did not always have theinformation needed to plan and deliver care andtreatment. From reviewing clinical records there wereentries made of diagnostic assessments which were notsupported by test results. Evidence showed that test resultswere not consistently being reviewed in a timely fashion.

    • On the day of the inspection we did not find anyoutstanding test results. However we reviewed a reportfrom the RCGP which indicated that when they beganworking with the practice there was a backlog of 12,000test results from between September 2016 to April 2017.The practice treated the incident as a significant event.The reason given for the backlog was that the clinicianswere not aware of how to archive results. The practicethen worked with the RCGP and put an action plan inplace to ensure that test results were acted upon withina reasonable timeframe and that the backlog of resultswas cleared. However we saw evidence that the RCGPhad undertaken a review of the system for managingtest results in mid July 2017 and found approximately250 results that had not been actioned or archived. Thisindicated that the system to ensure timely and safemanagement of patient test results was not effective orsustainable and we were told after our inspection thatthe practice did not routine review and action pathologyresults with a period of 48 hours and this was an arearequired further improvement. The action plan includedtraining for clinicians on how to manage and archivetest results. This training had not been completed at thetime of our inspection.

    • We were also provided evidence that from 9 September2016 to 25 March 2017 the practice had not completedany transfer of patient records for those patients whohad transferred to another GP and there was a backlogof 400. This placed patients at risk and undermined

    continuity of care as a patient’s new GP would not haveaccess to their medical information. This backlog wascleared prior to inspection after identification andprompting by the RCGP.

    • There was no failsafe system in place for monitoringreferrals for urgent tests and diagnosis from secondarycare. This was raised with the lead GP who produced anaudit of referrals for urgent tests with a view to assessingtheir appropriateness. The absence of a system forensuring that test results were received placed patientsat risk of harm as results could be may be missed oroverlooked.

    • The anomalies raised by the RCGP patient record auditand the lack of response from the practice to theconcerns raised called into question the integrity of thepatient record system. Therefore any documentedevidence in the patient record regarding external patientassessments or collaborative working could not berelied upon.

    It was evident that the practice had held discussions withboth the local safeguarding and palliative care team.However, there was no evidence of specific patients beingdiscussed with the health visitor team and the notes fromthe latest meeting appeared to only be a question andanswer session regarding local safeguarding procedures.The practice provided the inspection team with an emailsent to the palliative care team. The email indicated thatthere were 29 patients on the practice’s palliative careregister but only three of these were under the care of thepalliative care team at the time of their meeting with thepractice. The practice had undertaken a review of theregister after the meeting and identified another eightpatients who needed to be referred to the palliative careteam. This suggested that the register was not up to dateand review mechanisms were not effective enough toensure those patients at the end of their life were referredto the local palliative care team in a timely manner whenthe need arose.

    Consent to care and treatment

    Staff were able to outline how they would seek patients’consent to care and treatment in line with legislation andguidance.

    • Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005.

    Are services effective?(for example, treatment is effective)

    Inadequate –––

    21 Dr Sharif Hossain Quality Report 09/11/2017

  • • When providing care and treatment for children andyoung people, staff carried out assessments of capacityto consent in line with relevant guidance.

    • Where a patient’s mental capacity to consent to care ortreatment was unclear the GP or practice nurseassessed the patient’s capacity and, recorded theoutcome of the assessment.

    Supporting patients to live healthier lives

    Patients with chronic diseases were not correctly coded onthe clinical system which called into question the accuracyof the practice’s disease registers. This could have hinderedthe practice’s ability to provide care or refer these patientsfor additional support.

    The practice’s uptake for the cervical screening programmewas 74%, which was comparable with the CCG average of77% and the national average of 81%.

    As the practice nurse was not available on the day of theinspection we were unable to confirm how the practicefollowed up patients who did not attend for their cervicalscreening test and we were not able to establish if therewas a failsafe systems to ensure results were received for allsamples sent for the cervical screening programme and

    that women who were referred as a result of abnormalresults were followed up. Rates of screening for bowelcancer screening were lower when compared to the localand national average: 36% compared with 43% in the CCGand 58% nationally.

    Childhood immunisation rates for the vaccinations werecomparable to the national averages. There are four areaswhere childhood immunisations are measured; each has atarget of 90%. The practice had not achieved the target inany of four areas. These measures can be aggregated andscored out of 10, with the practice scoring 8.5 (compared tothe national average of 9.1). The practice informed us thatthey had achieved 90% for all immunisation targets for thecurrent year.

    Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74. Questionsraised by the review of patient records and the practice’spersistent failure to review test results in a timely fashion orimplement a system to monitor urgent test results meanthat we could not be assured that appropriate follow-upswere made, when abnormalities or risk factors wereidentified.

    Are services effective?(for example, treatment is effective)

    Inadequate –––

    22 Dr Sharif Hossain Quality Report 09/11/2017

  • Our findingsAt our last inspection undertaken on 22 September 2016the practice was rated as good for the key question: Areservices caring? However, we recommended that thepractice take action to improve the identification of carersand advertise bereavement services. At this inspection wefound that the practice had increased the numbers ofpatients identified as having caring responsibilities and hadinformation related to bereavement services in the waitingarea. However, some patients provided negative feedbackregarding the attitude of reception staff, there were limitedinstances of care planning and some of the informationavailable in the reception area regarding other health andsupport services was out of date. Consequently thepractice is now rated as requires improvement for caring.

    Kindness, dignity, respect and compassion

    During our inspection we observed that members of staffwere courteous and helpful to patients and treated themwith dignity and respect.

    • Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments.

    • Consultation and treatment room doors were closedduring consultations; conversations taking place inthese rooms could not be overheard.

    • Reception staff knew that if patients wanted to discusssensitive issues or appeared distressed they could offerthem a private room to discuss their needs.

    • Patients could not always be treated by a clinician of thesame sex. The practice employed a locum female GP onan adhoc basis.

    All of the 24 patient Care Quality Commission commentcards we received were positive about the clinical careprovided. Patients said they felt the practice offered a goodservice and that clinical staff were helpful, caring andtreated them with dignity and respect. Two of the commentcards raised concerns about the attitude of the receptionteam.

    We spoke with eight patients including two members of thepatient participation group (PPG). They told us they weresatisfied with the care provided by the practice. Comments

    highlighted that clinical staff responded compassionatelywhen they needed help and provided support whenrequired. However six of the patients we spoke with raisedconcerns about the attitude of the reception team.

    Results from the national GP patient survey showedpatients felt they were treated with compassion, dignityand respect. The practice in line with local and nationalaverages for its satisfaction scores on consultations withGPs and nurses but feedback regarding reception staff wasbelow average. For example:

    • 79% of patients said the GP was good at listening tothem compared with the clinical commissioning group(CCG) average of 86% and the national average of 89%.

    • 79% of patients said the GP gave them enough timecompared to the CCG average of 82% and the nationalaverage of 86%.

    • 94% of patients said they had confidence and trust inthe last GP they saw compared to the CCG average of94% and the national average of 95%

    • 83% of patients said the last GP they spoke to was goodat treating them with care and concern compared to thelocal average of 82% and the national average of 86%.

    • 83% of patients said the nurse was good at listening tothem compared with the clinical commissioning group(CCG) average of 85% and the national average of 91%.

    • 84% of patients said the nurse gave them enough timecompared with the CCG average of 87% and the nationalaverage of 92%.

    • 95% of patients said they had confidence and trust inthe last nurse they saw compared with the CCG averageof 94% and the national average of 97%.

    • 87% of patients said the last nurse they spoke to wasgood at treating them with care and concern comparedto the local average of 85% and the national average of91%.

    • 73% of patients said they found the receptionists at thepractice helpful compared with the CCG average of 85%and the national average of 87%.

    Care planning and involvement in decisions aboutcare and treatment

    There was limited evidence of care planning for patients inthe practice. The clinical lead had completed one of three

    Are services caring?

    Requires improvement –––

    23 Dr Sharif Hossain Quality Report 09/11/2017

  • care planning training sessions since the RCGP wasrecruited to support the practice yet care plans had onlybeen drafted for patients on the practice’s palliative careregister.

    However, patients told us they felt involved in decisionmaking about the care and treatment they received. Theyalso told us they felt listened to and supported by staff andhad sufficient time during consultations to make aninformed decision about the choice of treatment availableto them. Patient feedback from the comment cards wereceived was also positive and aligned with these views.

    We were told by staff that children and young people weretreated in an age-appropriate way and recognised asindividuals.

    Results from the national GP patient survey showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment. Results were in line with local andnational averages. For example:

    • 80% of patients said the last GP they saw was good atexplaining tests and treatments compared with the CCGaverage of 83% and the national average of 86%.

    • 72% of patients said the last GP they saw was good atinvolving them in decisions about their care comparedto the local average of 77% and the national average of82%.

    • 82% of patients said the last nurse they saw was good atexplaining tests and treatments compared with the CCGaverage of 84% and the national average of 90%.

    • 76% of patients said the last nurse they saw was good atinvolving them in decisions about their care comparedto the local average of 79% and the national average of85%)

    The practice provided facilities to help patients be involvedin decisions about their care:

    • Staff told us that interpretation services were availablefor patients who did not have English as a first language.We saw notices in the reception areas informingpatients this service was available and there was anelectronic sign in system in the patient waiting area.

    • Information leaflets were available in easy read format.

    Patient and carer support to cope emotionally withcare and treatment

    Patient information leaflets and notices were available inthe patient waiting area however much of this informationwas out of date. For example we saw signs for mentalhealth support group meetings which took place in 2015and information about baby and lung health clinics dated2012. The practice did not have a website which displayedhealth promotion or information about local supportservices.

    The practice’s computer system alerted GPs if a patient wasalso a carer. At the last inspection we found that thepractice had identified less than 1% of their patient list ashaving caring responsibilities. At this inspection thepractice had identified 120 patients as carers (2% of thepractice list). There was a poster in the reception areadirecting carers to a local support group.

    Staff told us that if families had experienced bereavement,their usual GP contacted them. This call was eitherfollowed by a patient consultation at a flexible time andlocation to meet the family’s needs and by giving themadvice on how to find a support service. At our lastinspection there was no information on local bereavementservices in the waiting area. We found on this inspectionthat bereavement services were now being advertised inreception.

    Are services caring?

    Requires improvement –––

    24 Dr Sharif Hossain Quality Report 09/11/2017

  • Our findingsAt our last inspection undertaken on 22 September 2016the practice was rated as good for key question: Areservices responsive to people’s needs? However, werecommended that the practice work to improve patientsurvey scores regarding access to a preferred GP andawareness of translation services.

    Though translation services were now being advertised,feedback from patients indicated concerns among somepatients around access to appointments and waiting times.In addition lack of effective multidisciplinary working andlack of effective management of the practice’s chronicdisease registers limited the practice’s ability to respond tothe needs of patients in their care. Consequently thepractice is now rated as requires improvement for beingresponsive to people’s needs.

    Responding to and meeting people’s needs

    The system for coding chronic disease patients raisedquestions about the accuracy of the practice’s long termdisease registers and there was limited evidence of workingwith external healthcare organisations includingsafeguarding and palliative care. This showed that thepractice did not have adequate mechanisms to enablethem to be responsive to the needs of their population. Inaddition some patients we spoke with reported difficultiesin accessing appointments.

    • The practice had no website where patients could bookappointments, order repeat prescriptions or obtaininformation about patient services. The practice told usthey were in the process of putting a website in placeand that patients could still access these services viaPatient Access.

    • The practice did not have a permanent female clinicianand this was raised as an issue by two patients on theday of the inspection. The practice told us they hadinterviewed a female clinician and were waiting untilafter the inspection to offer them a position at thepractice.

    • Care planning had been highlighted as a concern by theRCGP both in respect of the quality and accuracy ofplans produced. Practice staff were in the process ofcompleting a course in care planning and had draftedcare plans for palliative care patients. The practiceinformed us they had 29 patients on their palliative care

    register and that three of these patients were under thecare of the palliative care team. The practice told us thatafter a recent meeting with the palliative care team anadditional five patients had been identified whorequired palliative care. This highlighted that thepractice did not have adequate systems in place toidentify patients who required additional support andensure that these patient’s needs were met.

    • The practice offered extended hours between 6.30 pmand 8 pm on Monday and between 6.30 pm and 7 pmTuesday to Friday for working patients who could notattend during normal opening hours.

    • There were longer appointments available for patientswith a learning disability.

    • Home visits were available for older patients andpatients who had clinical needs which resulted indifficulty attending the practice.

    • Same day appointments were available for children andthose patients with medical problems that require sameday consultation.

    • Patients were able to receive travel vaccines availableon the NHS as well as those only available privately.

    • The practice had translation services but no hearingloop for patients who were hard of hearing or deaf.

    Access to the service

    The practice opened at 8.30 am Monday to Friday andclosed at 8 pm on Mondays and 7 pm Tuesday to Friday.Appointments were available during these times. Extendedhours appointments were offered between 6.30 pm and 8pm on Mondays and 6.30 and 7 pm Tuesday to Friday. Inaddition to pre-bookable appointments that could bebooked between two and four weeks in advance, urgentappointments were also available.

    Results from the national GP patient survey showed thatpatients’ satisfaction with how they could access care andtreatment was comparable to local and national averagesin some areas and lower in others:

    • 86% of patients were satisfied with the practice’sopening hours compared with the clinicalcommissioning group (CCG) average of 74% and thenational average of 76%.

    • 54% of patients said they could get through easily to thepractice by phone compared to the local average of 74%and the national average of 71%.

    Are services responsive to people’s needs?(for example, to feedback?)

    Requires improvement –––

    25 Dr Sharif Hossain Quality Report 09/11/2017

  • • 82% of patients said that the last time they wanted tospeak to a GP or nurse they were able to get anappointment compared with the CCG average of 82%and the national average of 84%.

    • 62% of patients said their last appointment wasconvenient compared with the CCG average of 75% andthe national average of 81%.

    • 62% of patients described their experience of making anappointment as good compared with the CCG averageof 69% and the national average of 73%.

    • 21% of patients said they don’t normally have to waittoo long to be seen compared with the CCG average of51% and the national average of 58%.

    Around half of the patients told us on the day of theinspection that they were able to get appointments whenthey needed them. The other half told us that they haddifficulty accessing appointments and that they wouldhave to wait considerable amounts of time to getappointments including one patient who said that theywould have to wait up to eight weeks for an appointmentwith their chosen clinician. We were also told by thesepatients that they had difficulty getting through on thetelephone to make appointments. We were told at our lastinspection that the practice had introduced a telephonequeuing system however at this inspection we were toldthat this had not been introduced but there were plans fora new phone system to be put in place. Staff also said that

    all patients preferred to see one clinician within thepractice which created delays for patients and one staffmember told us that they did not think there were enoughstaff to meet patient demand.

    The practice had a system to assess:

    • whether a home visit was clinically necessary; and

    • The urgency of the need for medical attention.

    In cases where the urgency of need was so great that itwould be inappropriate for the patient to wait for a GPhome visit, alternative emergency care arrangements weremade. There was an emergency protocol available in thereception area. Clinical and non-clinical staff were aware oftheir responsibilities when managing requests for homevisits.

    Listening and learning from concerns and complaints

    The practice had a system for handling complaints andconcerns.

    • Its complaints policy and procedures were in line withrecognised guidance and contractual obligations forGPs in England.

    • There was a designated responsible person whohandled all complaints in the practice.

    • We saw that information was available to help patientsunderstand the complaints system in the receptionarea.

    We did not review any complaints received by the practiceor the responses issued to patients.

    Are services responsive to people’s needs?(for example, to feedback?)

    Requires improvement –––

    26 Dr Sharif Hossain Quality Report 09/11/2017

  • Our findingsAt our previous inspection on 22 September 2016, we ratedthe practice as inadequate for providing well-led servicesas the breaches found in respect of safe and effectiveservices indicated deficiencies in governance particularly inrespect of significant events, medicines and riskmanagement and a lack of quality improvement work. Inaddition the practice did not have effective policyframework in place.

    We found that some of the concerns identified on our lastinspection had not been adequately addressed. We alsoidentified new concerns associated with the practice’sleadership which put patients at risk; particularly in respectof oversight of the clinical record system and managementof test results and urgent diagnostic referrals. The practice’scurrent vision and strategy was limited and staff had onlyrecently been provided with legal contracts ofemployment. Consequently the practice is still rated asinadequate for providing well led services.

    Vision and strategy

    The practice lacked a clear vision to deliver high qualitycare and promote good outcomes for patients.

    • Discussions with the staff at the practice indicated a lackof a coherent strategy and vision. We were told that thefact that the practice was in special measures hadhindered the organisations ability to plan for the future.When asked about future planning the practice told usabout a number of options including partnership ormerger but did not seem to be clear about which optionthey would likely choose in the event that they came outof special measures or how long these would take toimplement. We were provided with differentexplanations regarding how the practice manager rolewould be replaced after the inspection. None of theoptions presented were sufficient to ensure the effectivemanagerial oversite necessary to ensure patient safety.For example it was clear from the options consideredthat the practice had not considered the competenciesrequired to fulfil the practice manager role.

    Governance arrangements

    The practice’s governance arrangements were inadequateand the lack of good governance placed patients at risk forexample:

    • The staffing structure in the practice was not alwaysclear. When we asked certain staff about roles andresponsibilities, for example who took responsibility forthe management of patient safety alerts, staff wereunable to provide a consistent answer.

    • The practice lacked effective policies and processes.There was no fire safety policy and the policy forsignificant events was from another GP practice. It wasevident that the practice did not have adequateprocesses in place to ensure that pathology results werebeing consistently reviewed and actioned. There wasalso no system in place for monitoring referrals forurgent diagnostic assessments and tests.

    • The practice did not have systems and processes inplace to enable them to accurately assess theirperformance. For example reviews of clinical recordsindicated that the practice were not correctly codingpatients with chronic diseases which meant that therewas uncertainty as to whether or not those patientswere being provided with the required care andtreatment. This called into question the accuracy of theavailable performance data including the practice’s QOFperformance.

    • There was little evidence of audits which demonstratedimprovement in the quality of patient care.

    • The systems for identifying, recording and managingrisks were not effective and did not ensure patient orstaff safety. In addition to the lack of systems formanaging patient safety alerts there was ineffectiveoversight of infection control concerns and insufficientattention to fire safety. Furthermore the systemic issuerelated to poor record keeping posed a serious potentialrisk to all patients within the practice.

    • We saw evidence that practice meetings were occurringon a regular basis.

    Leadership and culture

    The lead GP failed to demonstrate the required level ofleadership and ability to ensure high quality care. Fromreviewing records patient care was not provided in a safeway.

    There was a lack of effective leadership within the practiceand until recently staff did not have valid employmentcontracts in place and had no access to holiday, sickness orpension benefits.

    Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

    Inadequate –––

    27 Dr Sharif Hossain Quality Report 09/11/2017

  • There was limited evidence of multidisciplinary working.We saw little evidence of meetings held with the practicehealth visitor or safeguarding team with the exception ofone meeting where team practice hosted the safeguardingteam to give a generalised talk on safeguarding.

    • Staff told us the practice held regular team meetingsand we saw minutes from these meetings.

    • Staff told us there was an open culture within thepractice and they had the opportunity to raise anyissues at any time and felt confident and supported indoing so. However, despite being told by staff duringinterviews that they felt respected we found thatadministrative staff had not been provided with legalcontracts of employment. Upon further investigation itwas evident that staff were not receiving either statutoryholiday entitlement or sickness pay. New contracts ofemployment had been put in place once the RCGPbegan supporting the practice.

    The provider was aware of and had systems to ensurecompliance with the requirements of the duty of candour.(The duty of candour is a set of specific legal requirementsthat providers of services must follow when things gowrong with care and treatment). Staff were able to speakopenly. We saw an example where the duty arose anddemonstrated that the practice had systems to ensure thatwhen things went wrong with care and treatment:

    • The practice gave affected people reasonable support,truthful information and a verbal and written apology.

    • The practice kept written records of verbal interactionsas well as written correspondence.

    Seeking and acting on feedback from patients, thepublic and staff

    There was limited evidence that the practice listened andacted upon feedback from staff and patients. The patientparticipation group was not active and it was evident thatstaff did not have valid conditions of employment despitestaff having asked for full employment rights both ininformal discussions with the lead GP and managementand in their appraisals:

    • The practice did not have an active patient participationgroup (PPG). We spoke with a member of the PPG whoinformed us that the practice had not held any meetingssince our last inspection. However, they were able todetail suggestions that they had personally given to thepractice in the past including hiring a permanent femaleGP, having walk in appointments and using telephoneappointments.

    • It was evident from reviewing appraisal forms andspeaking with staff that they had raised concerns abouttheir terms of employment with the leadership in thepractice. However, it was only when the RCGP reviewedstaff terms of employment that changes were made totheir contracts.

    Continuous improvement

    There was no evidence of work aimed at continuouslearning and improvement within the practice.

    Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

    Inadequate –––

    28 Dr Sharif Hossain Quality Report 09/11/2017

    Dr Sharif HossainRatingsOverall rating for this serviceAre services safe?Are services effective?Are services caring?Are services responsive to people’s needs?Are services well-led?

    ContentsSummary of this inspectionDetailed findings from this inspection

    Overall summaryLetter from the Chief Inspector of General Practice

    The five questions we ask and what we foundAre services safe?Are services effective?

    Summary of findingsAre services caring?Are services responsive to people’s needs?Are services well-led?The six population groups and what we foundOlder peoplePeople with long term conditions

    Summary of findingsFamilies, children and young peopleWorking age people (including those recently retired and students)People whose circumstances may make them vulnerablePeople experiencing poor mental health (including people with dementia)What people who use the service say

    Summary of findingsDr Sharif HossainOur inspection teamBackground to Dr Sharif HossainWhy we carried out this inspectionHow we carried out this inspectionOur findings

    Are services safe?Our findings

    Are services effective?Our findings

    Are services caring?Our findings

    Are services responsive to people’s needs?Our findings

    Are services well-led?