Archived: Dr Krishna Chaturvedi Also known as Southbourne Grove Surgery

Letter from the Chief Inspector of General Practice

On 3 March 2016 we carried out a comprehensive inspection at Dr Krishna Chaturvedi. Overall the practice was rated as requires improvement. The practice was found to be inadequate in safe. It was rated as requires improvement for the effective and well-led domains and good in caring and responsive.

As a result of that inspection we issued the practice with requirement notices and a warning notice in relation to the governance at the practice, staff training and recruitment. We did not carry out a focused inspection to check for compliance with the warning notice.

We then carried out an announced comprehensive inspection at Dr Krishna Chaturvedi on 31 May 2017 to re-rate the practice and to check that the practice had complied with the warning notice. Overall the practice is rated as inadequate.

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

• Staff were not able to recognise and report significant incidents. There were two clinical significant events that had been documented with lessons learned however there was no evidence that these had been discussed in any meetings. The complaints that we reviewed showed that they had been investigated with outcomes and learning identified. We did not see any evidence of sharing with practice team. Staff that we spoke with were unable to recall any complaints discussed.

• Risks to patients and staff were not assessed and managed. The practice had not completed a health and safety risk assessment, a fire risk assessment or a legionella risk assessment at this inspection even thought this had been identified at the inspection in March 2016.

• Clinical audits had not taken place to drive quality improvement.

• The practice had improved their prescribing behaviour regarding high risk medicines and reviews, monitoring had been completed.

• There was no evidence that the practice had actioned MHRA and patient safety alerts. The practice manager said that these were forwarded to the clinical staff to action. The GP said that none had been actioned for a number of years. There was no evidence to show otherwise.

• A review of practice policies had commenced and some policies had been updated. The practice did not have a whistleblowing policy, consent policy, chaperone policy or security of prescriptions policy. The ‘Looked after children’ policy mentioned a GP not employed at this practice and the safeguarding children and vulnerable adults policy referred to another practice.

• The practice staff had completed chaperone training.

• Administrative staff had received an appraisal. The nurse appraisal had not been completed at the time of our inspection. However, we were told that this was due to be booked in with the GP to complete.

• The practice staff, including nurse, administrative staff and practice management were unaware that the GP had a defibrillator in the treatment room for use in the event of a medical emergency. They had not received training in how to use a defibrillator should they need to use it.

• Not all staff had undertaken appropriate training in respect of their roles. For example, fire safety, MCA training, basic life support and infection control. However the nurse and the GP were booked to attend infection control training later in 2017.

• The practice had installed a hearing loop for patients who may have hearing impairments.

• Electrical equipment had been tested and fridge temperatures were being checked and recorded.

• Blank prescription forms and pads were not securely stored. There was one opened box under the reception desk. Reception staff told us that they would top up printers from the boxes and there were no systems in place to monitor their use.

• The practice had completed a fire drill following the new fire alarm system been installed.

• The practice held regular multi-disciplinary team meetings.

• Data from the national GP patient survey showed patients reported high levels of satisfaction with the practice nursing team and had trust and confidence in their GPs.

• Staff told us that there was no process or policy for bereavement. There was no process in place with regards to updating records and notifications.

• We reviewed a sample of patient records in relation to exception reporting and hypnotic prescribing and found that patient records did not always contain evidence of face to face reviews and reasoning for continuing on prescribed medication. There was no evidence in the patient records that there had been further attempts to engage with these patients.

• There was no system for employment checks to be carried out for all staff including locums. There was no evidence to show that the locum GP had completed safeguarding or basic life support training.

• There was no system in place to ensure that updates to NICE guidance were being read and followed by staff.

• We found some prescribing of medicines was not in line with clinical guidance. We reviewed six patients that had been prescribed hypnotics as the practice had been identified as an outlier in this area and found that out of the six that we viewed four were not appropriately prescribed or monitored.
• The practice’s computer system enabled the GPs to know if a patient was also a carer. We asked the practice how many carers they had identified. However, this information was not provided to us.
• The practice were unable to provide a consent policy on the day of the inspection. The practice did not obtain written consent for minor surgery such as incisions orjoint injections.

Importantly, the provider must:

• Ensure that an accurate, complete and contemporaneous record is maintained for every patient to include a record of the care and treatment provided to them and of decisions taken in relation to the care and treatment provided.

• Ensure that the risks to patient health, safety and welfare are assessed, monitored and managed, taking into account the most up to date evidence based guidance such as through the use of MHRA alerts. This includes identifying and managing risks to the health and safety of patients and staff. It also includes assessing and managing risks associated with health and safety, legionella and fire safety.

• 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 effective systems are in place that enable the provider to assess, monitor and improve the quality of the clinical care services provided. Assess whether clinicians have the up to date clinical information available to them and mitigating any such risks identified such as implementing a system of continuous clinical improvement initiatives.

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

• Ensure all blank prescriptions are handled in accordance with national guidance.

• Implement a formal system to disseminate and discuss NICE guidance to ensure all clinical staff are kept up to date.

• Ensure that staff undertake appropriate training in respect of their roles and responsibilities and to keep people safe. This includes fire safety, basic life support and infection control.

• Ensure staff are aware of and trained in the use of the defibrillator for use in the event of a medical emergency.

• Ensure written consent is gained from patients prior to minor surgery taking place.

Additionally the should:

• Embed the practice policies and procedures so that they are practice specific and reflect current legislation and guidance.

• Implement a process for bereavement for staff to follow with regards to updating records and notifications.

• Ensure there is a process and method for identification of carers and the system for recording this to enable support and advice to be offered to those that require it.

I am placing this service in special measures. 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