Archived: Dr R M, D R Patel

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dr R M and D R Patel’s practice in Dartmouth Medical Centre on 10 January 2017. Concerns relating to the lack of contemporaneous records were identified. Under Section 31 of the Health and Social Care Act 2008 conditions were imposed on the registration of the provider in respect of the following regulated activity: Treatment of Disease, Disorder or Injury from Dartmouth Medical Centre.

We carried out this focused inspection on 27 March 2017 to review the actions the practice had taken following the Notice of Decision and focussed on the areas relevant to the notice only. As a result this there is no rating awarded following this inspection. Our key findings at this inspection were as follows:

• At the previous inspection, the GP was unable to confirm if alerts received from the Medicines and Healthcare Products Regulatory Agency (MHRA) had been acted on. The practice had introduced a system to ensure safety alerts including those received from the Medicines and Healthcare Products Regulatory Agency (MHRA) alerts were actioned appropriately by clinical staff.

• At the inspection in January 2017 we found the patient record system in place did not demonstrate that contemporaneous patient records were held. We found that some handwritten consultations notes had not been added to the patient records. Those that had been attached to the electronic system were difficult to read or illegible. At this inspection a review of the system showed clinical notes continued to be handwritten, but a system had been put in place to ensure all consultation notes were scanned onto patients’ records on a daily basis. A record of checks was held by the practice; however some of the notes remained illegible.

• At the first inspection we found that non clinical staff were adding medicines to patients’ records on behalf of the GP partners. No checks were made by clinically trained staff to ensure medicines had been added correctly or that contraindications between medicines had been identified. We have since received assurances at the second inspection that all GPs take responsibility for ensuring accurate and appropriate records of medicines are in place.

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 R M and D R Patels practice in Dartmouth Medical Centre on 10 January 2017. Overall the practice is rated as Inadequate.

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

• The practice had lacked capacity and capability in clinical leadership to support either safe, high quality clinical care or to implement the improvement indicated via the vision and strategy.
• Staff understood their responsibilities to raise concerns, incidents and near misses and there was a system in place for reporting and recording significant events.
• Arrangements were in place to safeguard children and vulnerable adults from abuse, and local requirements and policies were accessible to all staff. The GP partner was unable to confirm there was a system in place to identify children and young people who have had a high number of A&E attendances. However, since the inspection we have received evidence to confirm that the practice had a system in place to ensure all children were followed up following frequent attendances at A&E.
• The practice had introduced a system to ensure safety alerts including those received from the Medicines and Healthcare Products Regulatory Agency (MHRA) alerts were actioned. However, on speaking with the GP we were unable to confirm these were acted on appropriately.
• Clinical staff did not always assess patients’ needs and deliver effective care in line with current evidence based guidance. For example, 10 medical records we reviewed did not contain an accurate, complete and contemporaneous record in respect of each patient’s consultation. This included an inadequate record of the care and treatment provided.
• Some of the patient records we reviewed showed care and treatment was not delivered in line with recognised professional standards and guidelines, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
• The practice had an electronic system to store patient records and to show the actions which had been agreed to meet patients' care, treatment and monitoring needs. However key members of the clinical team where unable to use this system meaning that care could be compromised. We also found that even where handwritten notes of the consultations had been made these were not reliably added to the patient records. The consultations that had been attached to the electronic system, were difficult to read or illegible. This increased the risk that information about treatments provided may be overlooked.
• Non clinical staff were adding medicines to patients’ records on behalf of the GP partners. No checks were made by clinically trained staff to ensure medicines had been added correctly or that contraindications between medicines had been identified.

• Some audits had been carried out however we saw no evidence that clinical audits were driving improvement in performance and patient outcomes.

• Patients said they found it easy to make an appointment with a GP and that there was continuity of care, with urgent appointments available the same day.

• Cleaning schedules were in place for the building, however there was no up to date schedule available for the cleaning of medical equipment after use.
• Patients we spoke with on the day, 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

However there were areas of practice where the provider must make improvements:

• Implement a systematic approach to care delivery and improvement underpinned by appropriate clinical leadership and managerial capacity.
• Ensure an accurate and contemporaneous record is kept for each patient, with detailed information in relation to their assessment of needs, planning and delivery of care and there is an effective system in place for ensuring patient records are completed by staff with the necessary skills and understanding.
• Ensure effective systems are in place for care and treatment to be delivered in line with national guidance and best practice guidelines. This is important to ensure patients receive appropriate care and reviews.
• Ensure effective governance, including assurance and auditing processes that drive improvement in the quality and safety of the services is in place. This includes both clinical and non-clinical governance arrangements that identifies, assesses and manages risks to patient safety; as well as monitors the quality of services provided.
• The provider must have processes and procedures to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. This includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005, how to assess mental capacity and an understanding of the Gillick competency test.
• Maintain records to evidence the receipt of and actions taken in respect of patient safety information received from the Medicines and Healthcare products Regulatory Agency (MHRA) alerts to ensure prescribing remains safe.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures. Services placed in special measures will be inspected again within six months.

Due to the nature of the concerns identified on this inspection urgent action has been taken, to protect the safety and welfare of people using this service. Under Section 31 of the Health and Social Care Act 2008 conditions have been imposed on the registration of the provider in respect of the following regulated activity: Treatment of Disease, Disorder or Injury from Dartmouth Medical Centre, 1 Richard Street, West Bromwich, B70 9JL West Midlands and Central Clinic, Horseley Road, Tipton, DY4 7NB West Midlands. Conditions on the provider’s registration have been imposed due to the seriousness of the lack of contemporaneous records available and took effect from 13 January 2017.

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 further urgent enforcement action could be taken. 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