Archived: Dr Sergio De Cesare Also known as Cherry Tree Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sergio De Cesare on 4 and 10 January 2017. The overall rating for the practice was inadequate and the provider was suspended for six months, a care taking practice was allocated to the practice and the practice was placed in special measures. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Dr Sergio De Cesare on our website at www.cqc.org.uk.

This inspection was undertaken following the period of suspension and special measures and was an announced comprehensive inspection on 6 July 2017. Overall the practice is still rated as inadequate.

Our key findings were as follows:

• The practice had a significant events policy. However not all members of staff were able to locate it on the practice’s computer system and no events had been recorded even though we were given recent examples of significant events.

• The practice had some policies and protocols but these were not fully embedded in practice and not all staff members were able to locate them.

• The practice had no vulnerable adults or safeguarding children register and not all staff members knew where to access the safeguarding policy. Staff members were unclear of who the safeguarding lead for the practice was and were unclear of the external safeguarding team contacts or when to use them.

• There were no systems to act on and mitigate risks associated with patient safety alerts.

• All staff had completed mandatory training but this had not been embedded into practice.

• Although the practice participated in the Quality and Outcomes Framework (QOF) no data had been submitted and they could not demonstrate how this was being monitored. Therefore the practice was unable to demonstrate outcomes and quality improvement for patients with long term conditions.

• There had been no audits undertaken since the last inspection, where we were shown one incomplete audit with no evidence of how action led to improvement.

• The process for prescribing repeat medicines did not always include a review of high risk medicines; for example we saw that mesalazine was prescribed without any recent blood tests.

• The practice had a system for monitoring the cold chain; however we found out of date typhoid and nasal flu vaccines in the vaccine fridges.

• Emergency medicines did not include ceftriaxone, (this is used for patients who are allergic to penicillin) and there was no water for injection.

• The practice did not use an interpreting service for patients who did not have English as a first language and did not use their hearing loop.

• There was no practice website, and online services such as appointment booking and prescription requests were not available.

• There were discrepancies about what was classified as a complaint and how these were recorded and responded to.

• Staff who acted as chaperones were trained for the role and had received disclosure and barring service checks; however they were unable to demonstrate that they could carry out the role effectively.

• There was minimal engagement with other providers of health and social care; the practice did not participate in any peer review or multidisciplinary meetings.

• There was no evidence of appraisals or personal development plans.

• The practice had identified none of its patients as a carer.

• The practice told us that they carried out monthly formal practice meetings; however other than a meeting that occurred in response to the inspection announcement, these were not documented, there were no agendas, minutes or noted actions for learning and improvement.

• The business continuity plan was not comprehensive and incomplete and the practice had not secured a buddy practice.

• The practice had a recently formed patient participation group and was in the process of gathering patient feedback.

• We saw that Legionella testing had been carried out.

• All electrical and clinical equipment had been tested and calibrated to ensure that it was fit for purpose and in good working order.

• Patient Group Directions (PGD) had been adopted by the practice to allow nurses to administer medicines in line with legislation. PGD’s are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.

• There were systems in place to ensure the regular monitoring of the defibrillator and oxygen in the practice.

• There was a failsafe mechanism for cervical cytology to ensure all test results were received by the practice and all inadequate tests were followed up.

There were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

• Ensure patients are protected from abuse and improper treatment.

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

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Ensure that all patients are treated with dignity and respect.

• Maintain appropriate standards of hygiene for premises and equipment.

• Review the system for promoting the availability of chaperones in the practice.

• Consider re-introducing a carers register with processes to identify carers so that sufficient support can be provided to them.

The provider of this service was suspended for six months, a care taking practice was put in place and the practice was placed in special measures in January 2017.

There had been some improvements made but more improvement was needed. The practice remained with a rating of inadequate and in special measures but the suspension was allowed to expire as it was recognised that the practice was unable to effectively bring about the changes required with the care taking practice in place.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of 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 to 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. 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 by adopting our proposal to remove this location or cancel the provider’s registration.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sergio De Cesare on 4 and 10 January 2017, the inspection was carried out over two days to ensure that all key practice staff members were available to contribute to the inspection. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment, the locum nurse was administering vaccinations without Patient Group Directions and actions including infection control audits and legionella testing had not been carried out.

• The practice had no policies or protocols to govern activity.

• There was no process for acknowledging and acting on patient safety alerts.

• Staff were not clear about significant events, reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.

• Patient outcomes were limited as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.

• There was insufficient detail paid to safeguarding, non-clinical staff had not been trained and could not demonstrate they understood their responsibilities to report concerns and were confused about who the lead in the practice was. There was also no protocol.

• Non clinical staff had no training appropriate to their roles and staff members had not received an appraisal or personal development plan. No staff members including clinical staff had received fire safety training and there was no fire risk assessment, no fire alarm testing or fire drills and fire extinguishers were last tested in October 2015.

• There was no failsafe mechanism for monitoring cervical cytology results.

• The practice did not make use of an interpreting service.

• The practice did not have a patient participation group and little attention was paid to gathering feedback from patients.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Appointment systems were not working well so patients did not receive timely care when they needed it.

• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

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

• Implement systems and processes to mitigate risks associated with infection control and legionella testing.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure Patient group directions are in place for any nurse working in the practice that give vaccines or immunisations.

• Identify and mitigate risks to patients safety ensuring the proper and safe management of medicines, that equipment used by the practice is safe and in good working order and risks associated with cold chain maintenance is mitigated.

• Introduce systems to ensure all clinicians are kept up to date with national guidance and guidelines.

• Consider a programme of clinical quality improvement such as the introduction of clinical audits, including re-audits to ensure improvements have been achieved.

• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

• Introduce and maintain a comprehensive and up to date business continuity plan, with copies available off site.

• Implement a failsafe mechanism for monitoring cervical cytology results.

The areas where the provider should make improvement are:

• Review systems for identifying carers to ensure appropriate support is provided to them.

• Consider using an interpreting service to allow patient choice over whether they use family or friends as an interpreter.

Following the inspection on 10 January 2017 urgent action was taken to suspend the practice for six months.

I am placing this service in special measures.

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. 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 service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice