Archived: Dr Daya Nand Das Also known as Direct Access Surgery

Updated 3 January 2017

The practice had been previously inspected on 25 February 2016. Following this inspection the practice was rated Inadequate. The practice was placed in special measures and two warning notices were issued for regulations 12 (Safe Care and Treatment) and 17 (Good Governance). A focussed inspection took place on 29 July 2016 to monitor progress by the practice on the breaches of regulations detailed in the warning notices. The findings of the focused inspection demonstrated improvement in response to the warning notices served.

This practice is located in Leigh and is also known as Direct Access Surgery. The practice provides services from a modified terrace house. Consultation rooms are on both ground floor and first floor (for suitable patients). At the time of our inspection there were just over 1500 patients registered with the practice. It is a member of NHS Wigan Borough Clinical Commissioning Group (CCG).

There are a higher proportion of patients above 65 years of age (21%) than the practice average across England (17%). There are a high proportion of patients registered who have a long standing health condition (68%) compared to the CCG (57%) and National (54%) averages. Data showed there was a 25% turnover of patients per year.

There is one GP (male). There is also a practice manager and two supporting administration and reception staff. There is a female locum GP used by the practice on a Monday afternoon but there are no practice nursing staff.

The practice delivers commissioned services under the Personal Medical Services (PMS) contract. It offers direct enhanced services for the childhood vaccination and immunisation scheme, facilitating timely diagnosis and support for people with dementia, influenza and pneumococcal immunisations, minor surgery, patient participation, rotavirus and shingles immunisation and unplanned admissions.

The practice is open from 9am to 6.30pm from Monday to Friday with the exception of Thursday when there are extended hours are 8am to 7.30pm and Wednesday when the practice closes at 1pm. Cover is provided through the out of hours service on a Wednesday afternoon.

Patients can book appointments in person or via the phone. Emergency appointments are available each day. There is an out of hours service available provided by Bridgewater Community Health Care Trust and commissioned by Wigan Borough CCG.

Updated 3 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Das on 6 October 2016. Overall the practice is now rated as requires improvement.

The practice had been previously inspected on 25 February 2016. Following this inspection the practice was rated overall inadequate with the following domain ratings:

Safe – Inadequate

Effective – Inadequate

Caring – Requires improvement

Responsive – Requires improvement

Well-led – Inadequate

The practice was placed in special measures and two warning notices were issued for regulations 12 (Safe Care and Treatment) and 17 (Good Governance).

A focussed inspection took place on 29 July 2016 to monitor progress by the practice on the breaches of regulations detailed in the warning notices. The findings of the focused inspection demonstrated improvement in response to the warning notices served.

Following this re-inspection on 6 October 2016 our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However there was no evidence to demonstrate learning and positive outcomes for patients.
• Risks to patients were assessed and managed.

• The GP assessed patients’ needs and delivered care in line with current evidence based guidance. However there were no assurances that any locum or temporary staff used by the practice had the appropriate training, skills or knowledge.
• At the time of inspection the practice did not have any practice nursing staff to support the GP and we saw no evidence of any future arrangements to address this.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
• The practice had adequate facilities and was equipped to treat patients and meet their needs.
• There was evidence of clinical audits but some had not had a completed cycle. We saw minimal evidence that audits were driving improvement in performance to improve patient outcomes.
• There was a leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on and there was an active patient population group (PPG).
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Investigate safety incidents more thoroughly and ensure that any learning from these is cascaded to staff.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision to include robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
• Put systems and processes in place in place to ensure all clinicians, including locum GPs, are kept up to date with national guidance and guidelines.

In addition the provider should:

• Consider employing a practice nurse to contribute to patient care as soon as reasonably possible.
• Ensure clinical waste bins are out of reach of children
• Ensure all clinical audits demonstrate a two audit cycle to support quality improvement for patient outcomes.

I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 3 January 2017

The practice is rated as requires improvement for the care of people with long-term conditions. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group.

• The GP had the lead role in chronic disease management and patients at risk of hospital admission were identified as a priority.

• Longer appointments and home visits were available when needed.
• All these patients had a named GP and an annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• The percentage of patients on the diabetes register, with a record of a foot examination and risk classification, was 62% which was significantly below the national average of 88%. At previous inspections the practice could not offer an explanation as to why this was so low or demonstrate a plan to improve these results. At this inspection we saw evidence the practice had taken some action to address this shortfall with the contracted provider of this service. This was by writing to the podiatry service to ask for more timely access to appointments for their patients. However the GP had not taken any action to address this shortfall within the practice.
• There was no practice nurse to contribute to the care of this patient population group.

Updated 3 January 2017

The practice is rated as requires improvement for the care of families, children and young people. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were generally comparable to Clinical Commissioning Group (CCG) and national averages for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives and health visitors.
• There was no practice nurse to contribute to the care of this patient population group.

Updated 3 January 2017

The practice is rated as requires improvement for the care of older people. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group. .

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• There was no practice nurse to contribute to the care of this patient population group.

Updated 3 January 2017

The practice is rated as requires improvement for the care of working age people. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 3 January 2017

The practice is rated as requires improvement for the care of people experiencing poor mental health. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group. However, there were examples of good practice.

• 79% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is below the CCG and national averages.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• 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.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 3 January 2017

The practice is rated as requires improvement for the care of people whose circumstances make them vulnerable. The provider was rated as requires improvement for safe, effective and for well-led. The issues identified as requires improvement overall affected all patients including this population group.

• The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• 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 was no practice nurse to contribute to the care of this patient population group.