Archived: Dr Shibopriyo Mukhopadhyay Also known as Ashfield Medical Centre

Updated 12 May 2016

Dr Mukhopadhay’s practice provides primary medical care services to approximately 3400 patients in Sutton-in-Ashfield in North Nottinghamshire. The practice is based at a single location: at Ashfield Medical Centre, King Street, Sutton-in-Ashfield, Nottinghamshire NG17 1AT.

The practice has an increasing patient list size including a growing Polish population who represent 13.3% of the total patient population. The salaried GP speaks Polish, which enables patients’ to access a GP who can converse with them in their preferred language.

Dr Mukhopadhyay is a single handed GP and is supported by a salaried GP who provides nine sessions over a two week period. Both GPs are male. The nursing team comprises of two part-time practice nurses and a healthcare assistant. The clinical team is supported by the practice manager and four staff undertaking administrative and / or reception roles.

The practice has a Primary Medical Services (PMS) contract with NHS England. This is a contract for the practice to deliver primary care services to the local community or communities. Services offered include immunisations for children, foreign travel, minor surgery, diabetic clinic and ear syringing.

The practice is open between 8.30am and 6.30pm Monday to Friday. Appointments are available from 9am to 12.10pm on Monday, Wednesday and Friday; and from 3.30pm to 5.40pm daily. On Tuesday and Thursday morning appointments are offered from 10am to 12.10pm. Extended surgery hours including a lunchtime clinic are offered subject to patient demand. The practice has opted out of providing the out-of-hours services to their own patients. This is provided by Central Nottinghamshire Clinical Services (CNCS).

The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of: diagnostic and screening procedures; family planning, maternity and midwifery services; surgical procedures and treatment of disease, disorder or injury. The practice has been inspected on the following dates:

• 24 March 2015 under the new comprehensive inspection programme. The practice was rated Inadequate overall and placed in special measures for a period of six months.

A focused inspection was undertaken on 18 December 2015 to follow-up a Warning Notice issued where improvements were required by 1 December 2015. The practice complied with the Warning Notice.

Updated 12 May 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Shibopriyo Mukhopadhyay’s practice on 25 February 2016. Overall the practice is rated as requires improvement.

Our previous comprehensive inspection carried out in March 2015 found breaches of legal requirements (regulations) relating to safe, effective, responsive and well led domains. In addition, all population groups were rated as inadequate due to the concerns found in these domains. The overall rating from the March 2015 inspection was inadequate and the practice was placed into special measures for six months.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements. At this inspection we found some improvements had been made in relation to safe, responsive and well led domains; however the practice had not made sufficient improvements to comply with two of the regulations they were previously in breach of. This related to safe care and treatment and good governance.

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

• The practice had improved its systems and processes for assessing and monitoring identified risks to try and ensure patients were kept safe. This included: carrying out suitable checks for staff undertaking chaperone duties and those recently recruited, auditing of infection control practices and increasing the clinical staffing levels.

• The practice had implemented improvements to the appointment system to enable patients to have easy access to the service. Most patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day. However, robust arrangements were still required to ensure appropriate GP cover was in place during planned or unplanned absences.

• The systems for recording, monitoring and reviewing information about safety had been strengthened. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

• Improvements had been made to ensure effective care and treatment was provided for patients with diabetes, depression and chronic obstructive pulmonary disease.

• Some staff did not assess patients’ needs and deliver care in line with current evidence based guidance. For example, the care and treatment of patients identified as requiring a minor surgical procedure had not been provided in a timely way, the quality of note taking was poor and did not demonstrate effective follow up action to determine patient outcomes. Due to these concerns we took urgent enforcement action to minimise any further risks to patients.

• Improvements were still required to ensure clinical audits and re-audits were undertaken in line with best practice guidance to improve patient outcomes.

• Clinical performance data showed patient outcomes were at or below the local and national averages.

• Staff were supported with their professional development; however arrangements for the supervision and appraisal of practice nurses required improvement to ensure they were fully supported by a clinician / GP.

• Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice had adopted an “open door” approach for carers to enable them to access support from practice staff as and when required.

• Patients had access to information about the service in appropriate languages and formats. This included English, Polish, Hindi and Punjabi.

• The practice had proactively sought feedback from staff and patients including the patient participation group (PPG). The practice worked closely with the PPG to promote patient education on the appropriate use of secondary care services.

• The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. However, the overarching governance framework did not always support the delivery of good quality care.

The areas where the provider must make improvements are:

• Ensure clinical audits and re-audits are carried out to improve patient outcomes. Specifically those relating to osteoporosis and minor surgery.

In addition the provider should:

• Continue to review the availability of non-urgent appointments and adjusting them in response to patient demand.

• Review and update the practice’s procedures and guidance as planned.
• Ensure proactive measures are taken to increase the uptake of cancer screening programmes.
• Ensure proactive identification of carers.

I confirm that this practice has improved sufficiently to be rated Requires Improvement overall. However, the practice has been rated as inadequate for the effective domain and as a result remains in special measures.

We took urgent enforcement action and served an Urgent Notice of decision imposing additional conditions on the provider’s registration in respect of carrying on the regulated activity, surgical procedures, from this location. The below conditions took effect from 3 March 2016 and will remain in force until removed by the Care Quality Commission (the CQC).

New conditions imposed:

1. The service must ensure that Dr Shibopriyo Mukhopadhyay does not carry on any surgical procedures with immediate effect.

2. Clinicians who carry out surgical procedures at the practice must have appropriate and up to date training in carrying out those procedures.

The registered provider must ensure that all persons involved in the delivery of the regulated activity ‘Surgical Procedures’ have received appropriate training which is documented, auditable and evidenced prior to any surgical procedures being carried on.

3. An audit of patients who have had minor surgery since 01 February 2015 must be carried out.

This is to ensure patients have received appropriate care and treatment, and to determine if any follow up actions are needed to ensure patient safety.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate 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 varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 May 2016

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

• Nursing staff had lead roles in chronic disease management and had received additional support from community specialist nurses. Records reviewed showed improved outcomes for the care of patients with diabetes, depression and chronic obstructive disease. For example:

• Practice supplied data for 2015/16 showed an achievement of 87.8% for performance indicators related to diabetes. This was a significant improvement of 32% when compared to the 2014/15 achievement of 55.8%. The practice supplied data had not yet been verified or published.

• We received positive feedback from the diabetes specialist nurse in relation to the practice staff’s proactiveness in improving patient outcomes and the structured system in place to review the care needs of patients with diabetes.

• The number of GP appointments had increased and patients had access to home visits and longer appointments when needed.

• Patients had a named GP and a structured annual review to check their health and medicines needs were being met. The systems in place for inviting patients for their regular checks had also been strengthened.

• Patients at risk of hospital admission were identified as a priority and monthly multi-disciplinary team meetings were held to coordinate the care of patients with complex/multiple health needs.

• A self-care event had been planned for March 2016 and external organisations such as Diabetes UK had been invited.

Updated 12 May 2016

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

• There were systems in place to identify and follow up children living in disadvantaged circumstances and those who were at risk. For example, children and young people who had a high number of A&E attendances.

• The 2014/15 data showed immunisation rates were relatively high for all standard childhood immunisations. However, practice supplied data for 2015/16 showed the practice’s immunisation rates were below CCG average as at 31 December 2015.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We received positive feedback from the midwife attached to the practice. They confirmed the practice provided a responsive service when safeguarding concerns were raised and systems were in place to safeguard patients.

• The patient participation group (PPG) was actively recruiting for young people and an open door approach was offered to young carers to ensure they were seen when they turned up at the practice.

Updated 12 May 2016

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

• Care and treatment of older people did not always reflect current evidence-based practice. For example, the practice’s report titled “a therapy review of osteoporosis” was not in line with the National Institute for Health and Care Excellence (NICE) guidelines in respect of assessing the risk of fragility fracture in patients; and this had not been reviewed since our March 2015 inspection.

• Our review of the osteoporosis register showed only one patient aged 75 and over, had been listed and was being treated with bone sparing agent.

• Practice supplied data showed 69% of people aged 65 or over had received a seasonal flu vaccination and this was in line with the CCG average of 69.1%.

• Longer appointments and home visits were available for older people when needed.

• An open door approach for carers had been introduced and a self-care event with Age UK had been planned for March 2016.

Updated 12 May 2016

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

• The age profile of patients at the practice is mainly those of working age, students and the recently retired and most of the services reflected the needs of this group.

• The practice offered online services including booking of appointments, prescription ordering and electronic prescribing.

• Health promotion advice was offered and a range of health screening that reflects the needs for this age group were offered.

• The uptake of NHS health checks for people aged 40–74 had significantly increased since our last inspection. We found 110 health checks had been completed for 2015/16 compared to 30 health checks that had been completed in 2014/2015.

• The Public Health data showed the practice’s national cancer screening uptake was lower than the CCG and national averages.

• The patient participation group (PPG) were considering holding their meetings outside of working hours to encourage participation by working age people.

• The practice now offered GP appointments from 9am at least two or three times week. Some patients we spoke with acknowledged the improvement but felt further improvements were required for those wishing to access appointments outside of standard working hours (early mornings or late evenings).

Updated 12 May 2016

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

• The 2014/15 data showed performance for mental health related indicators was 100% compared to the CCG average of 91.1% and national average of 92.8%. However, the exception reporting rate was significantly above the CCG and national averages for four of the six mental health related indicators. The practice had an average exception rate of 37.7% compared to a CCG average of 14.9% and national average of 11.1%.

• Practice supplied data showed:

  - 14 out of 17 patients on the dementia register had been reviewed in the last twelve months.

  - 91.6% of eligible patients on the mental health register had a comprehensive care plan in place.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

• Patients had access to counselling services twice weekly from the practice.

• The practice website included signposting information for a dementia support group and mental health services.

Updated 12 May 2016

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

• The practice held a register of patients with a learning disability and annual health checks had been offered to all 13 patients. Ten out of 13 patients had received an annual health check and additional reviews had been scheduled for two other patients in March 2016.

• The practice worked with multi-disciplinary teams in the case management of vulnerable people. Home visits and longer appointments were offered when needed.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

• There were arrangements in place to allow people with no fixed address to register or be seen at the practice.