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

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

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Dr Das on 25 February 2016. Breaches of regulations were found and two warning notices were issued. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12 (Safe Care and Treatment)

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 17 (Good Governance)

We undertook this focused inspection on 29 July 2016 to check that they had followed their plan and to confirm that they now met the legal requirements in relation to the warning notices we issued. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Daya Nand Das on our website at www.cqc.org.uk.

Our key findings were as follows:

• The practice had introduced health and safety risk assessments including for control of substances hazardous to health (COSHH), infection control and Legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
• All staff who undertake chaperoning duties had a Disclosure and Barring Service check.
• The practice manager was the lead for infection control and updated cleaning schedules were in place.
• There was a fire risk assessment, newly installed smoke alarms and regular fire drills.
• The premises was clean and tidy, and remedial works and decorating had been undertaken.
• The practice had an updated business continuity plan.
• There was now suitable disabled access to the downstairs toilet and treatment room.
• The practice had purchased an oxygen cylinder.
• There was an incident reporting policy in place.
• There were up to date practice meeting minutes produced.
• Practice policies and procedures had been reviewed to ensure they were in date and fit for purpose.
• There was a system in place for disseminating alerts to staff.
• The GP provided cover for the nurse in cases of emergency.
• Staff had an up to date appraisal that included learning and development needs.
• Whilst there was some significant event analysis there was no systematic process to review these.
• The practice had a process in place to identify some vulnerable patients such as those with learning disabilities and homeless people.
• There was no formal process for keeping locum GPs or temporary staff updated with any national guidelines and guidance.
• There was evidence of clinical audits but some had not had a completed cycle.
• There was no evidence presented to indicate actions to address low Quality Outcomes Framework (QOF) scores or a plan to improve these results.

The findings of the this focused inspection demonstrated improvement in response to the warning notices served. It is important that the improvements found are further embedded and sustained. The practice remains in special measures, and we will undertake a further fully comprehensive inspection later in the year. It is at that inspection where the quality rating previously awarded will be reviewed.  

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 Das on 25 February 2016. Overall the practice is rated as inadequate.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough, outcomes were not shared and learning was not cascaded to staff.
• Risks to patients were assessed and managed.
• Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

• Information about services was available but not everybody would be able to understand or access it. For example there were different languages across the patient population but no information available in appropriate languages and formats.
• The practice had a number of policies and procedures to govern activity, but the majority were overdue a review.
• There were no robust infection prevention and control measures in place.
• There were no health and safety risk assessments or checks in place such as fire safety and legionella. The practice did not have oxygen available in case of emergency.
• Disabled access to the treatment rooms and other facilities was limited.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about how to complain was available.
• Patients said they found it easy to make an appointment with a named GP, with urgent appointments available the same day.
• The practice had sought feedback from patients and had a patient participation group.

The areas where the provider must make improvements are:

• Investigate safety incidents thoroughly and ensure that any learning from these is cascaded to staff.
• Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
• Ensure that all clinical audits demonstrate a two audit cycle to support quality improvement for patient outcomes.
• Put assurances in place in place to ensure all clinicians, including locum GPs and the practice nurse, are kept up to date with national guidance and guidelines.
• Take action to address identified concerns with infection prevention and control practice including legionella and Control of Substances Hazardous to Health risk assessments.
• Undertake a fire risk assessment as a matter of urgency and introduce regular alarm testing and evacuation drills.
• Put in place a business continuity plan in the event of an unforeseen emergency incident or event.
• Have oxygen available in the event of a medical emergency.
• Ensure recruitment arrangements include all necessary employment checks for all staff including DBS for those staff undertaking chaperone duties.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements

In addition the provider should:

• Provide practice information in appropriate languages and formats.
• Review and update procedures and guidance.

I am 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