GPPractices - 1-509910553 Dr Zaheer Hussain (24/07/2018 ... · trainingin2016andthreeclinicalandeightnonclinical staffhadcompletedthistrainingin2018,withthe certificatesfortwostaffdemonstratingitwasdonein

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 location Inadequate –––

Are services safe? Inadequate –––

Are services effective? Inadequate –––

Are services caring? Good –––

Are services responsive? Inadequate –––

Are services well-led? Inadequate –––

DrDr ZZaheeraheer HussainHussainInspection report

322 Lillie RoadFulhamLondonSW6 7PPTel: 020 7385 1964

Date of inspection visit: 24/07/2018 and 06/08/2018Date of publication: 17/12/2018

1 Dr Zaheer Hussain Inspection report 17/12/2018

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Inadequate

Are services well-led? - Inadequate

We carried out an announced comprehensive inspection atDr Zaheer Hussain, also known as Fulham Cross MedicalCentre, on 7 October 2014 under section 60 of Health andSocial Care Act 2008 as part of our regulatory functions. Theoverall rating for the practice was requires improvement insafe, effective, responsive and well-led domains, and goodin the caring domain. A second announced comprehensiveinspection was planned for 5 November 2015; however, theinspection team was refused entry by the RegisteredProvider, Dr Hussain. The inspection team attended thepractice on 10 November 2015 and conducted acomprehensive inspection. This resulted in the practicebeing rated as inadequate across all domains and thepractice was suspended for three months. The suspensionwas stayed following representations to the Judge, oncondition that a repeat inspection be conducted and iffound to be "good enough" the practice would be allowedto re-open. A further inspection was conducted on 4February 2016, the practice was rated inadequate overall,inadequate in well-led, safe and effective domains andrequires improvement in responsive and caring domains.The practice was placed in Special Measures. A six-monthinspection following Special Measures was carried out on15 September 2016 and the practice was rated overall asrequires improvement, requires improvement in effectiveand well-led domains and good in safe, caring andresponsive domains. The practice was taken out of specialmeasures. A twelve-month follow-up CQC inspection tookplace on 17 July 2017, at which the practice was rated asbeing good overall, with requires improvement in well-leddomain.

The full comprehensive reports of the previous inspectionscan be found by selecting the ‘all reports’ link for Dr ZaheerHussain on our website at www.cqc.org.uk.

This inspection, on 24 July 2018 was an announcedcomprehensive inspection with a second unannouncedvisit on 6 August 2018 to confirm that the practice was nowmeeting the requirements we had identified in well leddomain at our previous inspection on 17 July 2017.

At this inspection we found the practice demonstratedsome improvements from previous inspections, forexample, significant events, managing complaints andsharing learning with staff, and duty of candour andwhistleblowing policies were in place and staff understoodwhat is meant by those terms. However, improvementoverall had not been sustained, the provider had failed torespond to issues we have previously identified and raisedwith them. We found breaches in regulations 12 and 17. Inparticular:

• The practice did not have clear systems to manage riskso that safety incidents were less likely to happen. Whenincidents did happen, the practice did not always learnfrom them. Risk assessments were not being completed;staff recruitment was not in line with requirements;improvements were required to infection control andthere was no recent audit; equipment was not allcalibrated; there were fewer GP sessions provided thanat our last inspection when patient numbers hadincreased; there was no system to manage medicinesand safety alerts; prescribing and the management ofpatients being prescribed high risk medicines was notalways in line with guidance and requirements.

• There was limited evidence the practice reviewed theeffectiveness and appropriateness of the care itprovided. We found there was no induction for new staff,staff did not receive training needed to carry out theirrole, no appraisal, minimal evidence of qualityimprovement, no process to monitor consent. Therewere low numbers of women attending for a cervicalsmear and low child immunisations.

• Staff generally involved patients in their care andtreatment and treated patients with compassion,kindness, dignity and respect.

• The practice did not respond to patient needs byproviding safe and effective care and treatment. Therewas no evidence the practice had considered patientfeedback regarding access and taken action to improvepatient experience.

• There was a lack of governance and no systems in placeto assess, monitor and improve quality and safety, while

Overall summary


clinical meetings were taking place, these were notrecorded so there was no evidence of discussions oractions, the practice did not work with other health andsocial care services to provide joined up care andtreatment for patients.

The areas where the provider must make improvements asthey are in breach of regulations are:

• Ensure care and treatment is provided in a safe way topatients.

• Establish effective systems and processes to ensuregood governance in accordance with the fundamentalstandards of care.

I am placing this service in special measures. Servicesplaced in special measures will be inspected again withinsix months. If, after re-inspection, the service has failed tomake sufficient improvement, and is still rated asinadequate for any population group, key question or

overall, we will take action in line with our enforcementprocedures to begin the process of preventing the providerfrom operating the service. This will lead to cancelling theirregistration or varying the terms of their registration withinsix months if they do not improve.

This service will be kept under review and if needed couldbe escalated to urgent enforcement action. Wherenecessary, another inspection will be conducted within afurther six months, and if there is not enough improvementwe will move to close the service by adopting our proposalto remove this location or cancel this provider’sregistration.

Special measures will give people who use the service thereassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Overall summary


Population group ratings

Older people Inadequate –––

People with long-term conditions Inadequate –––

Families, children and young people Inadequate –––

Working age people (including those recently retired andstudents)

Inadequate –––

People whose circumstances may make them vulnerable Inadequate –––

People experiencing poor mental health (including peoplewith dementia)


Our inspection teamOur inspection team was led by a CQC lead inspector.The team included a GP specialist adviser, and a secondCQC inspector.

Background to Dr Zaheer HussainDr Zaheer Hussain, also known as Fulham Cross MedicalCentre, operates from 322 Lillie Road, Fulham, London,SW6 7PP. The practice has access to three consultingrooms which are based at ground floor level.

The practice provides NHS primary care services toapproximately 3100 patients and operates under aGeneral Medical Services (GMS) contract. The practice ispart of NHS North West London Clinical CommissioningGroup (CCG).

The practice is registered with CQC as an individualprovider, and the regulated activities provided arediagnostic and screening procedures, treatment ofdisease, disorder or injury and maternity and midwiferyservices.

The practice staff comprises a lead GP (8 sessions perweek), a GP partner not currently conducting clinicalsessions, two long-term female GP locums (0.2 wholetime equivalent (WTE) each). The medical team aresupported by a locum practice nurse (0.1 WTE) and one

healthcare assistant (0.1 WTE). There is a part-timepractice manager (0.4 WTE), a part-time assistant practicemanager (0.5 WTE) and four administration/receptionstaff (1.4 WTE).

The practice population is in the fifth decile in England,on a scale of one to ten, with one being the mostdeprived and ten being the least deprived. People livingin more deprived areas tend to have greater need forhealth services. Data shows that 30.4% of patients withinthe practice area were from Black and Minority Ethnic(BME) groups. The highest proportion of patients withinthe practice population were in the 15 to 44-year old agecategory.

The practice is open between 8am and 6.30pm Mondayto Friday. Extended hours appointments are available onMonday and Tuesday from 6.30pm to 8.30pm, and onWednesday from 6.30pm to 7.30pm. The practice doesnot currently have its own website, patients couldrequest appointments and repeat prescriptions on linethrough the NHS website. Out of hours services areprovided by London Central and West.

Overall summary


At our previous inspection on 17 July 2017, we ratedthe practice as good for providing safe services.

At our follow-up inspection on 24 July 2018 we foundconcerns in relation to medical indemnity insurance;safeguarding; the management of high riskmedicines; insufficient GP and nursing capacity; lackof a safe system in assessing patients wellbeing,prioritising and ‘red flag’ screening of patients; safestaff recruitment; a safe approach to InfectionPrevention and Control (IPC); Control of SubstancesHazardous to Health (COSHH) and premises/securityrisk assessments; safe medical equipment; storage ofvaccines prescribing and patient safety alerts.

Safety systems and processes

The practice did not have clear systems to keep people safeand safeguarded from abuse.

• The practice had systems to safeguard children andvulnerable adults from abuse but these were limitedand disorganised.

• All staff received up-to-date safeguarding and safetytraining appropriate to their role. However, they hadlimited knowledge of how to identify and reportconcerns. We saw evidence of one report of learningfrom safeguarding incidents were available to staff. Staffdid not take steps, including working with otheragencies, the lead GP told us the practice did not holdmulti-disciplinary meetings, to protect patients fromabuse, neglect, harassment, discrimination andbreaches of their dignity and respect. However, after theinspection the practice sent evidence of communicationwith the district nurse for one patient.

• The practice was unable to provide evidence thatrecruitment checks had been conducted on all staff.This included retention of interview notes, that tworeferences had been obtained for each member of staff,a signed confidentiality agreement was available andthat professional registrations and inclusion onperformer’s lists had been verified and documented.

• The practice told us there was a system in place tocheck the professional registration of clinical staff at thepoint of recruitment. However, they were unable toprovide evidence of this or a system in place to regularlymonitor this.

• The practice did not provide evidence of currentmedical indemnity insurance for all clinical staff.

• Staff who acted as chaperones were trained for theirrole and had received a DBS check. (DBS checks identifywhether a person has a criminal record or is on anofficial list of people barred from working in roles wherethey may have contact with children or adults who maybe vulnerable.)

• At the time of the inspection the practice was not able todemonstrate that all staff had received annual trainingfor infection control, basic life support and fire safetyawareness. After the inspection they sent details of thistraining for all staff, we noted two staff completed firesafety training after the inspection and two staff had notcompleted infection control training since 2017.

• Despite several requests and additional time beingallowed to provide the required information, thepractice has not provided evidence relating to the scopeand role of the healthcare assistant.

• The practice did not have an effective system to manageinfection prevention and control (IPC). The practice didnot demonstrate compliance with infection controlguidelines in relation to cleaning materials and storageof equipment. Arrangements in relation to IPC did notmitigate the risk of infection. For example, cleaningcloths were not colour-coded and were found clumpedtogether in a small cardboard box. This was a finding ofan Infection Control and Prevention (IPC) auditundertaken by the Commissioning Support Unit in May2017. The practice had not completed two action pointswithin their agreed action plan of twelve months. Theyhad not subsequently undertaken an internal IPC riskassessment within twelve months of the external audit.In addition, the practice could not provide a record toevidence decontamination of medical devices, forexample, ear irrigator and nebuliser.

We saw that IPC online training was made available to staff.Furthermore, the non-clinical lead for IPC had notundertaken enhanced training to support their role, andrecords show:

• On the day of inspection the practice were not able todemonstrate all staff had completed infection controltraining. After the inspection the provider sent copies ofcertificates confirming the cleaner had completed

Are services safe?



training in 2016 and three clinical and eight non clinicalstaff had completed this training in 2018, with thecertificates for two staff demonstrating it was done inSeptember 2018 which was after the inspection.

• The practice was unable to demonstrate that all staff indirect patient contact had received appropriatevaccinations in line with current Public Health England(PHE) guidance. The practice sent us evidence that onlyone member of staff who had direct patient contact hadcompleted a complete set of required immunisations.

• We saw that the practice had completed a LegionellaRisk Assessment, and regularly flushed taps and testedwater temperatures.

• The arrangements in place to ensure that facilities andequipment were safe and in good working order wereinsufficient. Although the practice could demonstratethat calibration of medical equipment had beenundertaken in July 2018, however they did not have asystem in place to check that calibration was up to datefor locums GPs using their own equipment.

• The practice did not provide evidence of riskassessments relating to the Control of SubstancesHazardous to Health, (COSHH) Premises and Securityand Health and Safety. However, after the inspection, aHealth and Safety risk assessment was submitted albeitwith an outstanding action point relating to a brokenglass door panel. A COSHH risk assessment was alsosent after the inspection, again this was incomplete, as itonly contained details of one cleaning material used atthe practice and contained details of risks not related tosubstances which may be hazardous to health. Apremises and security risk assessment was sent after theinspection.

• Arrangements for managing waste and clinicalspecimens kept people safe.

Risks to patients

The practice did not have adequate systems to assess,monitor and manage risks to patient safety.

• We found the practice had not adequately assessedrisks and monitored the impact on safety.

• Clinicians told us they knew how to identify and managepatients with severe infections including sepsis.

• The practice told us all calls were triaged by the doctoron duty. However, one of our inspectors sat with one ofthe non-clinical members of staff at reception andobserved that patients who called for an appointmentwere not appropriately managed. Patients wereinformed by staff there were no appointments availablethat day with no referral to a clinician for them to assessand there was no waiting list in place for appointmentcancellations. There was no triage of these patientsundertaken; patients were not asked if they required anurgent appointment or if the patient was experiencingany ‘red flag’ symptoms. Red flag symptoms which mayindicate a patient is suffering from potentiallylife-threatening disease, for example, shortness ofbreath or chest pains. Patients were not heard to beoffered any appointments within the group of practicesin the area or signposted to other services, for example,Urgent Care facilities, NHS 111, OOH services.Non-clinical staff told us they had not had red flagsymptoms training to recognise those in need of urgentmedical attention. However, after the inspection thepractice sent evidence they had appointment slotsavailable

• Arrangements were in place for planning andmonitoring the number and mix of non-clinical staffneeded to meet patients’ needs, including planning forholidays, sickness, busy periods and epidemics.However, we were unable to see evidence of how GPand nursing staff hours were effectively managed duringannual leave and when the service was under pressuredue to patient demand. The practice sent a copy of thebusiness continuity plan after the inspection, this notedthe arrangements with two neighbouring practices tosupport during staff shortages due to sickness.

• There was not an effective induction system fortemporary staff tailored to their role.

• The practice was equipped to deal with medicalemergencies and some staff were suitably trained inemergency procedures. Not all staff had undergoneannual basic life support(BLS) and fire safety training.Consequently, some staff had limited knowledge andunderstanding regarding their responsibilities tomanage emergencies on the premises.

• When there were changes to services or staff thepractice did not assess and monitor the impact onsafety.

Are services safe?



Information to deliver safe care and treatment

Staff did not have the information they needed todeliver safe care and treatment to patients.

• The care records we saw showed information needed todeliver safe care and treatment was not available tostaff. The practice did not have a documented approachto managing test results, although we did not findevidence of test results that were awaiting medicalreview.

• The practice did not have systems for sharinginformation with staff and other agencies to enablethem to deliver safe care and treatment.

• Clinicians made some timely referrals in line withprotocols.

Appropriate and safe use of medicines

The practice did not have reliable systems forappropriate and safe handling of medicines.

• The systems for managing and storing medicines,including vaccines, medical gases, emergencymedicines and equipment did not minimise risks.

• The practice told us that emergency equipment waschecked by the lead GP, however we were unable to seeevidence that this had been done or recorded on anongoing basis. The oxygen masks and nebuliser maskswe examined did not have an expiry date. A face mask inplace inside the emergency bag appeared dirty, lookedused, and was not in a sealed bag.

• The practice provided records for six months confirmingtemperatures from the vaccine fridge had remainedwithin acceptable limits, between 2oC and 8oC. Bestpractice guidance recommends that a secondthermometer or a temperature data logger should beused as a failsafe measure. However, although thepractice had a data logger, this was not working and wewere told this had not been operational for several days.

• Staff did not prescribe, administer or supply medicinesto patients or give advice on medicines in line withcurrent national guidance.

• The practice did not have a system in place to auditprescribing of all prescribers.

• The practice did not audit the prescribing of controlleddrugs. The practice had had a significant event in 2015

when a prescription for 2160 Fentanyl patches wasissued. The practice had failed to continue monitoringprescribing to ensure this type of incident did not occuragain. In addition, we found evidence of inappropriateprescribing of controlled drugs.

• The practice had reviewed its antibiotic prescribing andacted to support good antimicrobial stewardship in linewith local and national guidance.

• Patients’ health was not monitored in relation to the useof medicines and was not followed up on appropriately.Patients were not involved in regular reviews of theirmedicines. The practice did not have a policy orprotocol in place for monitoring patients who had beenprescribed high-risk medicines. The lead GP told us thatpatients who have been prescribed high-risk medicineswere dealt with on an individual prescription basis afterchecking records for monitoring. The practice was notusing the patient record system which identified whenon patients on high risk medications were due to haveblood tests conducted. An alert was observed on apatients’ record, highlighting the necessity for bloodtests to be undertaken as high-risk medicines wereprescribed. However, the required blood tests had notbeen conducted despite an alert being present.

• We did not see evidence of a system in place regardingpatients who had passed the threshold for authorisednumber of repeat prescriptions. The practice wasunable to show us evidence that patients were called into see a GP for review.

• The practice was unable to demonstrate evidence of anaudit trail regarding the management of informationand changes to patient’s medicines including changesmade by other services. The lead GP told us of anincident relating to a patient and a delay that hadoccurred, in processing a change of a patient’s medicinefrom a hospital letter. Although the practice nowensured post was dealt with daily, we did not seeevidence this had been recorded as a significant eventto detail what actions had been taken by the practiceand that a written policy governing this had been put inplace.

Track record on safety

Are services safe?



• The practice did not have a good track record on safety.Issues found had been highlighted at previousinspections, and the practice has been unable tomaintain improvement.

• The practice did not use comprehensive riskassessments in relation to safety issues.

• The practice did not monitor and review activity. Thisled to a lack of understanding of risks and gave aninaccurate picture of safety that did not lead to safetyimprovements.

Lessons learned and improvements made

The practice had limited systems in place to learn andmake improvements when things went wrong.

• Staff we spoke with understood their duty to raiseconcerns and report incidents and near misses. Leadersand managers supported them when they did so.Although there was a system in place for recording andacting on significant events and incidents, there werelimited systems for reviewing and investigating whenthings went wrong. The practice had limited learning

from previous significant events included in the 2015CQC report, and in relation to one significant event wesaw, had not shared lessons with local practices,although latterly had identified they must act on this toimprove safety in the practice.

• The practice had recorded two significant events in thepast twelve and we saw that these had beeninvestigated and outcomes recorded.

• It was unclear which staff members received safetyalerts within the practice, and the practice was unableto demonstrate they had a written policy to refer to anda formal system to act upon those which were relevantto the practice. The lead GP told us there was no systemor policy in place to deal with safety alerts. The lead GPstated that both he and the practice manager receivedsafety alerts. However, the practice manager told us thatsafety alerts were dealt with by the lead GP and we sawevidence of one MHRA safety alert they had noted fromMarch 2018.

• Please refer to the Evidence Tables for furtherinformation.

Are services safe?



At our previous inspection on 17 July 2017, we ratedthe practice as good for providing effective services.

At our follow, up inspection on 24 July 2018 we havenew concerns regarding safe and effective managementof patients across all population groups using best practiceguidelines; consent; women’s health-cervical screening;childhood immunisations; quality improvement/clinicalaudit; risk assessments; staff training including specific roletraining and management of the healthcare assistant scopeand role; and clinical meetings.

We have rated the practice as inadequate forproviding effective services overall and across allpopulation groups.

Effective needs assessment, care and treatment

The lead GP we spoke with was unable to demonstratehow they assessed needs and delivered care and treatmentin line with current legislation, standards and guidancesupported by clear clinical pathways and protocols. Thepractice told us the lead GP kept up to date with currentevidence-based practice through annual appraisal andeducational updates. However, we did not see evidence ofan annual appraisal and educational updates wereinadequate.

• The practice had failed to ensure that clinical protocolswere available for the healthcare assistant (HCA) whichoutlined the framework for the management of specificclinical situations which had been assessed as withintheir scope of responsibility. There were no protocols tosupport these roles including defined circumstanceswhere patients should be referred to a GP for furtherassessment.

• Patients’ immediate and ongoing needs were not fullyassessed. This included their clinical needs and theirmental and physical wellbeing.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• The lead GP told us he was aware of appropriate tools toassess the level of pain in patients.

• Clinical staff advised patients what to do if theircondition got worse and where to seek further help andsupport.

Older people:

The practice is rated as inadequate for providing safe andwell-led services and for providing effective services, whichaffects all six population groups. This population group israted as inadequate overall.

• Older patients who are frail or may be vulnerable did notroutinely receive a full assessment of their physical,mental and social needs. The lead GP told us this wouldbe offered on an opportunistic basis. The practice usedan appropriate tool to identify patients aged 65 andover who were living with moderate or severe frailty.

• The practice followed up on older patients dischargedfrom hospital. However, we did not see evidence ofupdated care plans and prescriptions to reflect anyextra or changed needs.

• Staff had appropriate knowledge of treating olderpeople including their psychological, mental andcommunication needs.

People with long-term conditions:


• Patients with long-term conditions did not have astructured annual review to check their health. The leadGP told us they conducted polypharmacy reviews toensure the patient’s medicines needs were being met,however they do not have a system in place to riskmanage this. For patients with the most complex needs,the lead GP did not work collaboratively as part of themulti-disciplinary team with other health and careprofessionals to deliver a coordinated package of care.

• The practice did not provide evidence that staff whowere responsible for reviews of patients with long termconditions had received specific training.

• The lead GP told us that patients who had receivedtreatment in hospital or through out of hours servicesfor an acute exacerbation of asthma were followed upby the practice nurse. However, we did not see evidenceof this and the practice had reduced the practice nurse’shours from one whole day per week to one morning perweek, which would severely impact on her capacity toprovide the necessary level of care.

• The lead GP told us there was no audit of formalevidence as to whether adults with newly diagnosedcardiovascular disease were routinely offered statins forsecondary prevention. People with suspected

Are services effective?



hypertension were not routinely offered ambulatoryblood pressure monitoring and patients with atrialfibrillation were assessed opportunistically for strokerisk and treated as appropriate.

• The practice told us there was no current systematicprocess to demonstrate how patients with commonlyundiagnosed conditions are identified, for examplediabetes, chronic obstructive pulmonary disease(COPD), atrial fibrillation and hypertension. In addition,they told us they did not offer spirometry which wouldbenefit patients with respiratory disease.

• The Quality and Outcomes Framework (QOF) data for2016/2017 showed that outcomes for patients withlong-term conditions, for example diabetes,hypertension, atrial fibrillation and chronic obstructivepulmonary disease were comparable with local andnational averages.

• However, the Quality and Outcomes Framework (QOF)practice scores had deteriorated from 81% in 2016/2017to 71% 2017/2018. The practice shared this informationwith us on request and the figures for 2017/2018 havenot been validated or published to date. The cervicalscreening rate for the practice showed a significantnegative variation at 46%. Despite the low uptake andsignificant negative variation averages relating tocervical screening, the practice has reduced the practicenurse’s hours to one morning per week.

Families, children and young people:

The practice is rated as inadequate for providing safe andwell-led services and inadequate for providing effectiveservices, which affects all six population groups. Thispopulation group is rated as inadequate overall.

• The practice childhood immunisation rates for 2016/17show the percentage of children aged one withcompleted primary course of 5:1 vaccine as being 100%which is above rate set by the World Health Organisationtarget of 95%.

• However, the uptake rates for childhood immunisationrates for 2016/17 for children aged two years showed asignificant negative variation. The practice scoresincluded: PCV 55 %; Hib and Men C 46%; and MMR 55%The national target for England for this age group is80%. We noted that these childhood immunisation rateshad deteriorated from the rates achieved for 2015/16.The administration of childhood immunisations formsan integral part of the practice nurse’s role. Despite the

childhood immunisation rates being significantly belowthe national and the deterioration in childhoodimmunisation rates from the previous year, the practicehad reduced the practice nurse’s hours from one wholeday per week to one morning per week. Poor uptake ofchildhood immunisations had been a finding at ourprevious inspections.

• The practice did not provide evidence of safety nettingfor children. The lead GP told us that he did not holdmeetings with health visitors and communication andthis was carried out by individual discussion, howeverthe practice was unable to show us any evidence of thisor minutes from past meetings.

• The practice did not have arrangements in place forfollowing up failed attendance of children’sappointments following an appointment in secondarycare or for immunisation. The lead GP told us thepractice nurse followed up children who failed to attendappointments and for childhood immunisations.However, the practice had recently reduced the practicenurse’s hours from one whole day per week to onemorning per week which will severely impact on thepractice nurse’s ability to offer adequate care andcapacity to offer appointments.

• The Lead GP told us he referred pregnant and postnatalwomen to local services to ensure good clinicaloutcomes in line with best practice guidelines. Bestpractice guidelines include: vaccinations recommendedduring pregnancy, folic acid supplements, Vitamin Dsupplements for breastfeeding mothers, postnatalannual blood testing for women who had gestationaldiabetes and support. GP’s working in primary care areideally placed to commence high quality pregnancycare, because frequently women will attend the practiceto confirm their pregnancy.

Working age people (including those recently retired andstudents):


• The practice’s uptake for cervical screening was 46%,which was below the CCG average cervical screeningrates at 57% and the national average of 72% and belowthe 80% coverage target for the national screeningprogramme. The most recent achievement cervical




screening uptake rates are dated May 2018, which hasbecome available, was 50%. The data in relation to theuptake of cervical screening in England is provided andpublished by Public Health England.

• Cervical screening is an integral part of the practicenurse’s role. Despite cervical screening rates beingsignificantly below the national target and low cervicalscreening rates have been a finding of our previousinspections, the practice had recently reduced thepractice nurse’s hours from one whole day per week toone morning per week which will severely impact on thenurse’s ability to offer adequate care and capacity tooffer appointments.

• The practice’s uptake for breast screening was 51%, CCGaverage was 59% and the national uptake rate was70.3%. In relation to bowel screening, the practiceuptake rate was 29%, CCG 42.3% and national averagewas 55%. The lead GP did not provide any evidence ofhow the practice planned to increase attendance ratesand ensure patients attended, wherever possible, forbreast and bowel screening.

• The practice did not have systems to inform eligiblepatients to have the meningitis vaccine, for examplebefore attending university for the first time becausethey did not have a significant eligible patientpopulation. Students are at greater risk of developingmeningococcal A, B, C, W and Y. These bacteria cancause meningitis and septicemia and can become fatalwithin hours. Data available from NHS England shows usthat the 15-44-year-old age group is the largest patientdemographic at Fulham Cross Medical Centre.

• Patients had access to appropriate health assessmentsand checks including NHS checks for patients aged40-74. The lead GP told us the practice nurse was thelead professional in relation to conducting healthchecks. However, we did not see evidence ofappropriate follow-up on the outcome of healthassessments and checks where abnormalities or riskfactors were identified, because the practice nurse wasunavailable for interview. In addition, the practice hadreduced the practice nurse’s hours from one whole dayper week to one morning per week, which wouldseverely impact on her capacity to balance competingdemands on her time and to provide adequate care.

People whose circumstances make them vulnerable:

The practice is rated as inadequate for providing safe,effective and well-led services, and good for caring whichaffects all six population groups. This population group israted as inadequate overall.

• The lead GP did not provide evidence of arrangementsin place for end of life care, and told us this is discussedby individual GP follow up appointments. However,there were no formal care plans to safety net patientcare and preferences, and the lead GP was unsure howmany patients had died in their preferred place of death.The lead GP did not know how many patients had diedlast year who had been included on the palliative careQOF register and how many of those patients had anon-cancer condition.

• End of life care was not delivered in a coordinated waywhich considered the needs of those whosecircumstances may make them vulnerable. The practicedid not hold end of life care multi-disciplinary meetingsand we did not see evidence of care plans.

• The practice used QOF registers for patients living invulnerable circumstances including those with alearning disability. The practice did not keep registersfor other vulnerable patient groups, for example,homeless people and travellers.

• The practice did not have had a system in place forvaccinating patients with an underlying medicalcondition according to the recommended schedule, andthe lead GP told us this was achieved by individual GPconsultation and new patient health checks.

People experiencing poor mental health (including peoplewith dementia):


• The practice did not systematically risk assess andmonitor the physical health of people with mentalillness, severe mental illness, and personality disorderby providing access to health checks, interventions forphysical activity, obesity, diabetes, heart disease, cancerand access to ‘stop smoking’ services. This wasconducted by individual GP consultation. When patientsfailed to attend for administration of long termmedication, reception staff referred those patients to anindividual GP.




• The lead GP told us when patients were assessed to beat risk of suicide or self-harm, that another doctor withinthe practice had a special interest in mental health. Hewas unable to provide specific examples to demonstratethe practice had arrangements in place to help them toremain safe.

• 67% of patients diagnosed with dementia had their carereviewed in a face to face meeting in the previous 12months. This is statistically comparable to the CCGaverage 80% and the national average of 84%.

• 73% of patients diagnosed with schizophrenia, bipolaraffective disorder and other psychoses had acomprehensive, agreed care plan documented in theprevious 12 months. This is comparable to the CCGaverage of 88% and the national average of 90%

• The practice specifically considered the physical healthneeds of patients with poor mental health and thoseliving with dementia. For example, 83% of patientsexperiencing poor mental health had receiveddiscussion and advice about alcohol consumption. Thisis comparable to the CCG average 89% and the nationalaverage of 91%.

• Patients at risk of dementia were identified and offeredan assessment to detect possible signs of dementia.When dementia was suspected there was anappropriate referral for diagnosis.

• The lead GP told us there was a very low prevalence ofpeople with a learning disability within the practicepopulation of 0.1%. and that the practice offered annualhealth checks opportunistically.

Monitoring care and treatment

There was minimal evidence of quality improvement,including clinical audit, being carried out within thepractice. The practice provided an overview of two fullcycle audits completed in 2018, which were related toclinical record keeping and cervical screening.

The practice told us they engaged with the local MedicinesOptimisation Team to review prescribing but the lead GPtold us the practice did not audit prescribers overall, didnot audit controlled drugs prescribing and were unable toprovide any recent audits undertaken. Data showed thatantibiotic prescribing was low and other prescribing wascomparable to local and national averages.

The practice did not have a comprehensive programme ofquality improvement activity and did not routinely reviewthe effectiveness and appropriateness of the care provided.Clinicians did not take part in any local and nationalimprovement initiatives.

• We saw that QOF achievement for 2016/17 was 81%,compared to the CCG average of 92% and the nationalaverage of 96%. We asked the practice to provide uswith QOF data for 2018/19, which is yet unpublished andunvalidated, and we saw that QOF achievement haddeteriorated to 71%.

Effective staffing

Staff did not have the skills, knowledge and experience tocarry out their roles.

• Some staff did not have appropriate knowledge for theirrole, for example, to carry out reviews for people withlong term conditions, older people and people requiringcontraceptive reviews. We did not see evidence of rolespecific training for staff to enable them to provide goodcare for patients across all population groups.

• The lead GP had received cervical screening training,however, the practice nurse whose role includedimmunisation and taking samples for the cervicalscreening programme had not received specific trainingand could not demonstrate how they stayed up to date.Childhood immunisations and cervical screening are anintegral part of a practice nurse’s role.

• The provider did not have an overarching policy relatedto the scope of the healthcare assistant (HCA) and theroles carried out. This included outlining the frameworkfor the management of specific clinical situations ordefinition of circumstances where patients should bereferred to a GP for further assessment.

• We asked the practice for evidence of clinical protocolsrelating to specific tasks the HCA performed. Thepractice told us the HCA performed phlebotomy, ECG,blood pressure checks and health checks andsubmitted copies of two pages of what appears to be adiabetes workshop booklet, relating to the role andscope of the HCA. The practice did not understand thatspecific protocols must be in place relating to the roleand scope of the HCA, and they told us that all practicepolicies and protocols apply to the healthcare assistant.The practice had no assurance the HCA was onlycarrying out tasks they were trained and competent to.




• The practice did not meet the learning needs of staffalthough staff told us they were provided with protectedtime and training to meet their needs. The practice didnot maintain up to date records of skills, qualificationsand training. We did not see evidence of appropriatesystems in place to manage this, although staff told usthey were encouraged and given opportunities todevelop.

• The practice told us they provided staff with someongoing support, and that there was an inductionprogramme for new staff, supervision and revalidation.We were unable to see evidence of inductionprogrammes and the practice was unable to provideevidence for six out of 12 staff appraisals. Trainingrecords we saw were chaotic and incomplete, and sometraining was completed by staff immediately prior toand on the day of inspection.

• We did not see evidence of a clear approach forsupporting and managing staff when their performancewas poor or variable.

Coordinating care and treatment

Staff did not work together and with other health andsocial care professionals to deliver effective care andtreatment. The practice told us they did not participate inmulti-disciplinary team working, meetings and did notcurrently share information with the wider healthcare teamand other agencies.

• We did not see evidence to show that all appropriatestaff, including those in different teams andorganisations, were involved in assessing, planning anddelivering care and treatment.

• The practice did not share clear and accurateinformation with relevant professionals when discussingcare delivery for people with long term conditions andwhen coordinating healthcare for care home residents.They did not provide evidence they shared informationwith, and liaised, with community services, socialservices and carers for housebound patients and withhealth visitors and community services for children whohave relocated into the local area.

• We did not see evidence that patients receivedcoordinated and person-centred care. This includedwhen they moved between services, when they were

referred, or after they were discharged from hospital.The practice did not work with patients to developpersonal care plans that were shared with relevantagencies.

• The practice was unable to provide evidence thatreassured us end of life care was delivered in acoordinated way which considered the needs ofdifferent patients, including those who may bevulnerable because of their circumstances. The lead GPwas unsure as to any information in this regard.

Helping patients to live healthier lives

Staff were not consistent and proactive in helping patientsto live healthier lives.

• The practice did not have systematic risk assessmentprocesses in place to identify patients who may needextra support and direct them to relevant services. Thisincluded patients in the last 12 months of their lives,patients at risk of developing a long-term condition andcarers.

• We did not see evidence that staff encouraged andsupported patients to be involved in monitoring andmanaging their own health, for example through socialprescribing schemes. The lead GP told us that he hadgood awareness of local services and pathways but wasunable to cite or show us any examples of referringpatients via social signposting. However, a patient whois also a carer told us the practice referred people to theCarer’s Centre for support.

• The lead GP told us he discussed changes to care ortreatment with patients and their carers as necessary.

• The practice did not show us evidence to demonstratethey supported national priorities and initiatives toimprove the population’s health, for example, stopsmoking campaigns and tackling obesity.

Consent to care and treatment

The practice did not always deal with consent in line withlegislation and guidance.

• Clinicians understood the requirements of legislationand guidance when considering consent and decisionmaking. However, we did not see evidence thatclinicians supported patients to make decisions, or thatthey had assessed and recorded a patient’s mentalcapacity to make a decision.

• The practice did not have a system in place to monitorthe process for seeking consent appropriately.




Please refer to the evidence tables for furtherinformation.




At our previous inspection on 27 July 2017, we ratedthe practice as good for providing caring services. Thepractice is now rated as good for caring.

Kindness, respect and compassion

We observed staff treated patients with kindness, respectand compassion.

• Feedback from patients was positive about the way stafftreat people.

• Staff we spoke with demonstrated they understoodpatients’ personal, cultural, social and religious needs.

• We received 36 patient Care Quality Commissioncomment cards, all of which were positive about theservice, although six people complained about lengthywaiting times to see the GP in surgery. Patients told usthat staff were kind, helpful and caring and they weretreated with dignity and respect.

• The practice sought patient feedback through the NHSFriends and Family Test (FFT). Results for the periodJanuary 2018 to April 2018, showed that on average 91%of patients would be extremely likely to recommend theservice.

• We spoke with three patients during the inspection, whowere members of the patient participation group allwere positive about their experiences at the practice.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about careand treatment. They were aware of the AccessibleInformation Standard (a requirement to make sure thatpatients and their carers can access and understand theinformation that they are given.)

• Staff communicated with people in a way that theycould understand. For example, a hearing loop wasavailable, patients who first language was not Englishhad access to interpreter services and those with ahearing impairment to British Sign Language (BSL) We

saw the practice had designed a cervical smear easyread leaflet with visual cues for women whose firstlanguage was not English. The practice was not able toshow us evidence this had increased uptake rates.

• Staff helped patients and their carers find furtherinformation and access community and advocacyservices, for example, signposting them to the Carer’sCentre.

• The practice had recorded 17 carers which is less than1% of the practice population. We did not see evidenceof action taken to improve the number of carersidentified even though we have raised this at previousinspections.

• Results from the latest national GP patient surveyshowed patients on the whole responded positively toquestions about their involvement in planning andmaking decisions about their care and treatment. Forconsultations with GPs, we found that 99% of patientswho responded said they had confidence and trust inthe GP they saw or spoke with (CCG average 94%;national average 96% and 95% of patients whoresponded, stated that the last time they saw or spoketo a GP, the GP was good or very good at treating themwith care and concern (CCG average 82%; national 86%).For consultations with nurses, we found someresponses were in line local and national averages. Forexample, 100% of patients who responded said that thelast time they saw or spoke with a nurse, the nurse wasgood or very good at treating them with care andconcern (CCG average 85%; national average 91%).

Privacy and dignity

The practice respected patients’ privacy and dignity.

• When patients wanted to discuss sensitive issues, orappeared distressed reception staff offered them aprivate room to discuss their needs.

• Staff recognised the importance of people’s dignity andrespect.


Are services caring?

Good –––


At our previous inspection on 17 July 2017, we ratedthe practice as good for providing responsive services.The practice is now rated as inadequate for providingsafe, effective, responsive and well-led services, theissues identified affect all population groups whichare rated inadequate.

The practice told us it organised and delivered services tomeet patients’ needs, for example it provided extendedopening hours. Staff told us they understood the needs andpreferences of the local population but had not undertakenany formal analysis or needs assessment.

• The practice engaged a locum practice nurse one day perweek to undertake childhood immunisations and thecervical screening programme. Data showed that patientoutcomes were below target. Childhood immunisationshad been below target at our previous inspection. Thepractice had decreased its practice nurse availability sinceour previous inspection.

• The facilities and premises were sufficient for the servicesdelivered.

• The practice did not make reasonable adjustments whenpatients found it hard to access services.

• Care and treatment for patients with multiple long-termconditions and patients approaching the end of life was notco-ordinated with other services.

Older people:

People with long-term conditions:

The practice is rated as inadequate for providing safe,effective and well-led services and good for caring,which affects all six population groups. This

population group is rated as inadequate overall.

• The practice did not conduct systematic riskassessments using a failsafe approach to enablepatients with a long-term condition to receive an annualreview to check their health and medicines needs werebeing appropriately met. The lead GP told us this wasdone on an opportunistic basis.

• The practice did not hold regular meetings with thelocal district nursing team to discuss and manage theneeds of patients with complex medical issues.

Families, children and young people:

The practice is rated as inadequate for providing safe,effective and well-led services and good for caring,which affects all six population groups. Thispopulation group is rated as inadequate overall.

• We did not find systems in place to identify and followup children living in disadvantaged circumstances andwho were at risk, for example, children and youngpeople who had a high number of accident andemergency (A&E) attendances.

• We were not reassured that all parents or guardianscalling with concerns about a child were offered a sameday appointment when necessary.

Working age people (including those recently retiredand students):

The practice is rated as inadequate for providing safe,effective and well-led services and good for caring,which affects all six population groups. This

population group is rated as inadequate overall.

• The needs of this population group had been identifiedand the practice had adjusted the services it offered toensure these were accessible, flexible and offeredcontinuity of care. For example, the practice offeredextended opening hours on Monday and Tuesdayevening until 8.30 pm, on Wednesday evening until 7.30pm and offered telephone consultations.

People whose circumstances make them vulnerable:

The practice is rated as inadequate for providing safe,effective and well-led services and good for caring whichaffects all six population groups. This population group israted as inadequate overall.

• The practice used only QOF register of patients living invulnerable circumstances including those with alearning disability.

People experiencing poor mental health (includingpeople with dementia):

The practice is rated as inadequate for providing safe,effective and well-led services and good for caring whichaffects all six population groups. This population group israted as inadequate overall.

• Staff interviewed did not have a good understanding ofhow to support patients with mental health needs.

Are services responsive to people’s needs?



• For those patients living with dementia the practice hadmade some adjustments in relation to become adementia friendly practice. The practice did not provideevidence that clinical and non-clinical staff hadundertaken dementia awareness training.

• The practice did not routinely offer annual healthchecks to patients with a learning disability, only on anopportunistic basis, as numbers of patients with alearning disability are low at 0.1%.

Timely access to care and treatment

Patients could access care and treatment from the practicealthough sometimes patients experienced delays whenattending for appointments.

• Waiting times at the practice were often lengthy asreflected in patient feedback on comments cards andon NHS Choices and Google reviews websites, althoughstaff told us they did inform and apologise to patientsfor delays. However, we did not see evidence thepractice had responded to NHS Choices comments.

• Staff told us they could accommodate most patientswith an appointment or telephone consultation.Patients reported that the appointment system waseasy to use and they could get appointments when theyneeded them. However, our inspector observed thatpatients who called for an appointment were notappropriately managed. Patients were informed by staffthere were no appointments available that day andthere was no waiting list in place for appointmentcancellations. There was no triage of patientsundertaken; patients were not asked if they required anurgent appointment or if the patient was experiencingany ‘red flag’ symptoms. Patients were not offered anyappointments within the group of practices in the area.Patients were not signposted to other services, forexample, Urgent Care facilities, NHS 111, OOH services.

• Results from the latest national GP patient surveyshowed that patients’ satisfaction with how they couldaccess care and treatment was comparable to local andnational averages. For example, 91 % of patients whoresponded said they could get through easily to thepractice by phone CCG average 73% national average 71% and 87 % of patients responded positively to theoverall experience of making an appointment (CCGaverage 70 national average 73 %.

Listening and learning from concerns and complaints

The practice told us they took complaints and concernsseriously and responded to them appropriately to improvethe quality of care.

• Information about how to make a complaint or raiseconcerns was available. Staff we spoke withdemonstrated they would treat patients who madecomplaints compassionately.

• The complaint policy and procedures were in line withrecognised guidance.

• The practice had recorded six written complaints in thepast 12 months. The practice told us they also recordedverbal complaints but none had been received in thisperiod.

• We reviewed all the complaints and found that theywere satisfactorily handled in a timely way. We saw thatpatients had been contacted and offered face-to-facediscussions where appropriate.

• We were told that complaints were discussed in practicemeetings and minutes from meetings reflected thatcomplaints were shared with the team.


Are services responsive to people’s needs?



At our previous inspection on 17 July 2017 we foundthat the staffing structure had been strengthened andimprovement made following previous inspectionshad been sustained and further driven. However,there remained areas of weakness in relation toclinical outcomes and clinical leadership capacity.

At our follow-up inspection on 24 July 2018 we foundthe practice did not have clear systems in place toassess, monitor and improve the quality and safety ofthe service or to mitigate the risks associated withsafe care and treatment. The practice leadership didnot demonstrate that they had knowledge or capacityto oversee high quality safe care. The practice hadfailed to address some of the concerns from ourprevious inspection, had failed to providenotifications and action plans to CQC in line withregulations, failed to sustain improvements madeafter previous inspections and new concerns werefound on the day of the inspection.

The practice is now rated as Inadequate for providingwell-led services.

Leadership capacity and capability

The delivery of high-quality care was not assured by theleadership, capacity, skills, governance or culture at thepractice.

• There was a lack of clinical leadership and oversight atthe practice. Leaders lacked knowledge about issuesand priorities relating to the quality and future ofservices. Although the practice had previously beenrated inadequate and placed into special measures,they were unable to sustain improvements that hadbeen made. They lacked capacity and did notunderstand the challenges presented and thereforewere unable to address them.

• Leaders at all levels were visible and staff felt able toapproach them if necessary.

• The practice did not have effective processes to developleadership capacity and skills, including planning for thefuture leadership of the practice.

Vision and strategy

The practice’s mission statement was ‘to provide highquality of care and service, delivered by a dedicated teamof doctors with the support of a primary care team andwider health professionals to meet the needs of

individuals, as well as focusing on continued healthpromotion and chronic disease management, for bettermanagement of health problems and improved outcomes’.We did not see evidence of the practice working with otherhealthcare professionals in line with their missionstatement. The practice manager provided a business plandocument, however this had not been shared with any ofthe practice team.

Culture

Although practice leaders told us there was a culture todeliver high-quality sustainable care, we found the capacityto prioritise quality improvement was limited, there was apoor track record in terms of maintaining improvementand the practice was reactive rather than proactive.

However, staff we spoke with told us:

• They felt respected, supported and valued and therewere positive relationships between staff and themanagement team. They were happy to work at thepractice. They could raise concerns and had confidencethat these would be addressed. We saw from trainingrecords that staff had received duty of candour andwhistleblowing training.

• We saw evidence that only six out of 12 staff hadreceived an appraisal in the last year.

• We did not see evidence from training records that staffhad received equality and diversity training.

Governance arrangements

There were no clear responsibilities, roles and systems ofaccountability to support good governance andmanagement.

• Structures, processes and systems to support goodgovernance and management were ineffective. Theywere not consistently implemented or monitored andthere was a lack of day-to-day oversight by the leadersto ensure effective management of safety and risk.

• There was no evidence of regular structured orformalised clinical meetings to demonstrate sharedlearning. The practice told us that clinical meetings wereinformal communications and not minuted. We wereinformed that learning from significant events, patient

Are services well-led?



safety alerts, clinical guidance and complaints wasdiscussed in clinical and practice meetings, However,they could not provide evidence of this in the absence ofmeeting minutes.

• There was no formal system to act upon patient safetyalerts. The practice could not provide evidence of actiontaken regarding recent patient safety alerts, for example,patient searches.

• There were gaps in staff training and some training,including role-specific training, had not beenundertaken at a level and frequency outlined in its ownpolicy.

• Although staff we spoke with told us they were clear ontheir roles and responsibilities we found that somedelegated responsibility had not been undertaken andthere was insufficient management monitoring andoversight of this.

Managing risks, issues and performance

There were no clear and effective processes for managingrisks or prioritising quality improvement. In particular:

• The practice provided records for six months confirmingtemperatures from the vaccine fridge had remainedwithin acceptable limits, between 2oC and 8oC. Bestpractice guidance recommends that a secondthermometer or a temperature data logger should beused as a failsafe measure. However, although thepractice had a data logger, this was not working and wewere told this had not been operational for several days.A second thermometer provides a method ofcross-checking the accuracy of the temperature. If asecond thermometer is unavailable, the fridgethermometer should be calibrated monthly to confirmaccuracy.

• The practice had failed to address all the actions of riskassessments for health and safety and an infectionprevention and control audit (IPC). We saw that thepractice had completed a Legionella Risk Assessment,and regularly flushed taps and tested watertemperatures. However, we noted that hot water hadbeen tested and recorded at 50oC and not the minimumrequired standard of 55oC required for healthcarepremises.

• The arrangements the practice had in place in relationto infection prevention and control (IPC) did notmitigate the risk of infection.

• The practice had failed to maintain an inventory of allmedical equipment, and were unable to provideevidence that all medical equipment had beencalibrated in line with guidance. The practice wasunable to evidence when the equipment belonging tolong term locum GPs was last calibrated in line withguidance.

• The practice had failed to ensure that clinical protocolswere available for healthcare assistant's (HCA)'soutlining the framework for the management of specificclinical situations or definition of circumstances wherepatients should be referred to a GP for furtherassessment.

• There was minimal evidence of quality improvement,including clinical audit, being carried out within thepractice. The practice provided two full cycle auditsfrom 2018, one of which related to performance reviewof poor record keeping. in relation to the lead GP. Thesecond audit was an internal review of overall cervicalscreening rates. The lead GP told us that there had beenno recent formalised clinical audits undertaken.

• The practice had a business continuity plan andemergency equipment and medicines were available.

• Clinicians we spoke with knew how to identify andmanage patients with severe infections including sepsis.However, there was no red flag symptoms protocol,non-clinical staff were unable to demonstrate anunderstanding of red flag symptoms and how torespond and managers confirmed there had been noformal training.

• The provider had failed to take action following ourprevious inspections when we noted low number ofcarers had been identified, which had decreased from21 carers to 17 carers since our last inspection.

Appropriate and accurate information

We found the information used in reporting, performancemanagement and delivering quality care was not alwaysaccurate, valid, reliable, timely or relevant. Leaders andstaff did not always receive information to enable them tochallenge and improve performance. For example,concerns identified in 2014 regarding change of registration




status from being a single provider to a partnership had notbeen actioned, and staff responsible for making statutoryCQC notifications had not done so within requiredtimescales.

Engagement with patients, the public, staff andexternal partners

The practice told us it gathered feedback from patientsthrough the NHS Friends and Family Test (FFT), NHSchoices comments, comments and complaints receiveddirectly and its patient participation group (PPG). We spokewith three members of the PPG at the inspection, who toldus they met regularly. From the FFT, when asked how likelythey were to recommend their GP practice to friends andfamily if they needed similar care or treatment, patientssaid: January 2018 93%; February 2018 95%; March 2018

86%; and April 2018 88%. Staff we spoke with told us theywould not hesitate to give feedback and discuss anyconcerns they had. Six staff out of 12 had received anannual appraisal.

Continuous improvement and innovation

There is little innovation or service development. Theclinical and non-clinical leaders could not demonstratethat improvement was a priority as the practice had failedto sustain improvements made following previousinspections, which included a failure to comply with CQCnotification regulations. There was minimal evidence oflearning and reflective practice.





Action we have told the provider to takeThe table below shows the legal requirements that the service provider was not meeting. The provider must send CQC areport that says what action it is going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The practice did not have clear systems to keep peoplesafe and safeguarded from abuse:

• The provider had failed to provide evidence of currentmedical indemnity insurance for all clinical staff.

• The provider had failed to ensure that comprehensiverisk assessment systems were put in place across allpopulation groups, in line with best practice guidance.

• The provider had failed to ensure that patients withLong-Term Conditions or are regarded as being highrisk, had been comprehensively risk assessed and theircare had been safely managed.

• The provider had failed to provide assurance that thecold chain had been safely managed.

• The provider had failed to provide a fail-safe system inrelation to safeguarding vulnerable adults and children.

• The provider had failed to provide adequate GP andnursing capacity to safely meet patient’s needs.

• The provider had failed to ensure that prescriberswithin the practice and ensure that a regular plannedprogramme of audit in relation to prescribers at thepractice, is in place that meets with best practiceguidance.

• The provider had failed to provide safe management ofprescribing including controlled drugs and high riskmedicines.

• The provider had failed to implement a safe system ofappropriate triaging, prioritising and ‘red flag’ screeningof patients who requested an appointment, and thatstaff were trained to deliver this.

• The provider had failed to mitigate the risk of infectionand to provide a safe and effective approach to IPCincluding water testing relating to Legionella.

• The provider had failed to ensure premises andequipment are adequately risk assessed andmaintained in accordance with the latest guidance.

Regulation

This section is primarily information for the provider

Requirement notices


• The provider had failed to provide a system to ensurethat all patients who have abnormal test results aresafely managed.

• The provider had failed to provide safe recruitmentprocesses.

• The provider had failed to ensure that clinical protocolswere available for healthcare assistants outlining theframework for the management of specific clinicalsituations or definition of circumstances where patientsshould be referred to a GP for further assessment.

This was in breach of regulation 12 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

There was a lack of systems and processes establishedand operated effectively to ensure compliance withrequirements to demonstrate good governance. Inparticular we found:

• The provider had failed to significantly strengthen andsustain clinical leadership and oversight arrangements.

• The provider had failed to provide a failsafe system inrespect of patient safety alerts.

• The provider had failed to ensure that all staffemployed by the practice are appropriately trained andcompetent for the roles they perform.

• There was little evidence of quality improvement,including clinical audit being carried out within thepractice.

• There were gaps in staff training and some training,including role-specific training, had not beenundertaken at a level and frequency outlined in its ownpolicy. There was no formal strategy and business planwritten in line with health and social priorities of thearea or to meet the needs of the practice population.

• There was no evidence of structured clinical meetingsto demonstrate shared learning.

Regulation


Requirement notices


This was in breach of regulation 17 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.


Requirement notices


Documents

GPPractices - 1-509910553 Dr Zaheer Hussain (24/07/2018 ... · trainingin2016andthreeclinicalandeightnonclinical staffhadcompletedthistrainingin2018,withthe certificatesfortwostaffdemonstratingitwasdonein