The Care Quality Commission
  • Doctor
  • GP practice

Archived: Barking Road Medical Centre

Overall: Inadequate read more about inspection ratings

34 Barking Road, East Ham, London, E6 3BP (020) 8472 1347

Provided and run by:
Dr Samuel Ojo Ayodele Olatigbe

All Inspections

1 March 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 1 December 2015. At that inspection we found breaches of legal requirements and we issued an urgent suspension of the provider's registration for a period of three months to enable the provider to take action to improve while removing patients from the risk of harm.  The provider informed us that they were taking action to remedy the breaches. 

We undertook this focused inspection to check whether the practice was making progress in meeting legal requirements. This report only covers our findings in relation to those requirements. The report from our last comprehensive inspection can be found by selecting the 'all reports' link for Barking Road Medical Centre on our website at www.cqc.org.uk.

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

  • The practice had improved its approach to safety and had revised its policies and procedures and introduced new 'failsafe' procedures where appropriate.
  • All outstanding test results and clinical letters were being systematically followed up and referred to other agencies and health professionals in line with current guidelines.
  • The practice had considered its staffing needs and was in the process of securing locum GPs in readiness for reopening. It had safe recruitment procedures.
  • The practice had demonstrated the ability to learn from critical findings about its performance and had addressed issues raised at the last inspection. The root cause of the original failures remained unclear.
  • Shortly after our focused inspection visit, it became clear that the principal GP had withheld important information from their application to register as a provider with the Care Quality Commission. This reflected a serious failure of integrity in the leadership of the service.
  • Patients remained at risk of harm at this practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Barking Road Medical Centre on 1 December 2015. Overall the practice is rated as inadequate.

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

  • Patients were at significant risk of harm because systems and processes were not in place to keep them safe. Clinical letters received by post were left in boxes and had not been acted on, in some cases for over six months. These included abnormal test results and requests for information in relation to safeguarding cases.

  • Incidents were systematically under-reported and the practice was not always learning and improving when things went wrong.

  • Patient records we reviewed were not always accurate or complete. This made it difficult to assess whether the practice was providing safe and effective treatment in line with recommended local and national guidelines in the cases we reviewed.

  • The practice’s reported performance was in line with national and local averages for example, in relation to child immunisations and the Quality and Outcomes Framework.

  • Patient feedback was variable. We received positive comments about the service but also critical comments about problems with prescriptions. The 2016 National GP Patient Survey indicated patient satisfaction was poor with GP consultations and the service overall.

  • The service was open for extended hours and patients reported being able to book appointments when needed. The GP principal was routinely arriving late for clinical sessions and had been doing so for months. Patients and staff were not alerted to the likely length of delays. Staff told us they had been subject to verbal abuse as a result.

  • The practice had no system for documenting, analysing and learning from verbal complaints.

  • The practice did not foster a supportive, learning culture. Staff were discouraged from raising concerns about the service and fearful of the consequences. Many of the staff we spoke with were concerned that patients were not getting a high quality service from the practice.

The areas where the provider must make improvements are:

  • Introduce robust processes for reporting, recording, acting on and monitoring all significant events, incidents and near misses.

  • Ensure that patient records include all relevant information about patients’ treatment and care in line with professional requirements.

  • Ensure that governance arrangements include systems for dealing with all incoming clinical correspondence in a timely way.

  • Ensure that prescription requests are acted on in a timely way and can be tracked.

  • Ensure that staff understand the practice ‘whistleblowing’ procedure and their duty to escalate safety concerns if necessary.

  • Implement a review of clinical sessions provided to ensure that they routinely start at the advertised time.

  • Document verbal complaints and investigate and act on these as appropriate.

  • Ensure the accountable person understands the legal requirements relating to running a practice, (including CQC registration requirements and notifications) and when to seek additional support.

  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.

The areas where the provider should make improvements are:

  • Provide the clinical team with more opportunities to review incidents, unusual cases and complaints and share learning.

  • Ensure that reception staff are informed of any delays or absence of clinical staff.

  • Improve patient survey findings by involving patients in decisions about their treatment and care.

  • Demonstrate to staff that their concerns and ideas are discussed, taken seriously and addressed.

On 2 December 2015 we took urgent enforcement action to suspend Dr Samuel Olatigbe from providing general medical services at Barking Road Medical Centre under Section 31 of the Health and Social Care Act 2008 ("the Act) for a period of three months as a minimum to protect patients. We will inspect the practice again prior to the end of the three month suspension.

I am also placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice