Archived: Dr David Zigmond Also known as St James Church Surgery

Letter of the Chief Inspector of General Practice 

We carried out an announced comprehensive inspection of Dr David Zigmond on 5 July 2016. Overall the practice is rated as inadequate.

On the basis of our findings we made an application to Camberwell Magistrate’s Court on 11 July 2016 to urgently cancel the provider’s registration under section 30 of The Health and Social Care Act 2008 on the basis that there were several breaches of the 2014 Regulations which presented serious risks to people's life, health or well-being. including:

• Lack of emergency equipment

• Staff did not adequately assess consent and capacity

• The processes for managing and prescribing patient medication did not keep patients safe

• The processes in place to record and learn for significant events were not effective

• The practice’s procedures around child and adult safeguarding did not ensure that vulnerable people were kept safe.

• The practice did not comply with a number of current medical guidelines and best practice.

Other 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 had not been undertaken for staff prior to their employment and actions identified to address concerns with infection control practice had not been completed.

• Non-medical equipment had not had portable appliance testing since 2013 and there was no assessment of whether or not this equipment was safe to use.

• There was no oxygen or defibrillator on the premises. Staff at the practice told us of two instances where patients had collapsed in or near the surgery and no staff had completed basic life support training within the last 12 months. Staff had not received fire safety training, there was no completed fire safety risk assessment and the fire alarm was broken. Though the practice had business continuity arrangements in place the GP principal had no awareness of these.

• Systems around medicines management and treatment of patients with long term conditions or mental health concerns were inadequate. There was no effective system in place to ensure that patients were recalled for reviews and treatment provided often did not reflect current best practice and guidance. The outcome of which was reflected in the practice’s poor performance in a number of clinical areas relative to other practices nationally and locally.

• There were inadequate systems in place to safeguard people against abuse or harm and a number staff had no DBS certificates.

• Staff were not clear about reporting incidents, near misses and concerns. We identified several instances where significant events were not acted upon in accordance with practice policy.

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

• There was no evidence of patient or staff feedback being used to drive improvement.

• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However the practice only had a female nurse on site once a month and only provided nursing services between 9.30 am and 12.30 pm twice a week.

• The practice had no clear leadership structure and governance arrangements were either limited or ineffective.

Our application was successful and Dr Zigmond’s registration with the Care Quality Commission was cancelled on 11 July 2016

Had the provider’s registration not been cancelled, we would have set out the following list of ‘musts’ for their action:

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

• Assess and take action to address identified concerns with infection prevention and control

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

• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines and ensure that these are being followed consistently.

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

• 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.

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

• Ensure that adequate records are produced for each patient and that effective systems are put in place to ensure that patients are recalled and reviewed when required.

• Put in place appropriate systems to safeguard vulnerable children and adults.