The Care Quality Commission
  • Doctor
  • GP practice

Archived: Upminster Medical Centre

Overall: Inadequate read more about inspection ratings

224-226 St Marys Lane, Upminster, Essex, RM14 3DH (01708) 251407

Provided and run by:
Drs. SS & MM Baig

All Inspections

5 & 11 June 2020

During an inspection looking at part of the service

We carried out an unannounced focused inspection of Upminster Medical Centre on 5 June 2020 and a remote access clinical notes review on the 11 June 2020 as a result of concerns raised with the CQC.

At the last inspection in March 2017 the practice was rated as good overall.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected;
  • information from our ongoing monitoring of data about services; and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall.

We rated the practice as Inadequate for providing safe services because:

  • The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Staff did not have the information they needed to deliver safe care and treatment as patient medical records did not contain sufficient information to ensure safe continuity of care.
  • The practice did not have systems for the appropriate and safe prescribing of medicines.
  • The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the practice as Inadequate for providing effective services because:

  • Patients’ needs were not assessed, and care and treatment was not delivered in line with current legislation, standards and evidence-based guidance.
  • The practice could not demonstrate effective management for patients with long term conditions such as diabetes.
  • The practice was unable to demonstrate that it always obtained consent to care and treatment in line with legislation and guidance.

We rated the practice as Inadequate for providing well-led services because:

  • The practice could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective as policies and procedures were out of date and were not followed consistently.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not submit statutory notifications to the commission in a timely manner.
  • There was little evidence of systems and processes for learning and continuous improvem.t

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

7 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Upminster Medical Centre on 8 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Upminster Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 8 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At the last inspection we found arrangements around cleanliness and infection control were not adequate. There were also concerns around staff training and recruitment and risk monitoring. Arrangements in respect of clinical audits and staff appraisal needed improving. We also found policies were not all adapted to the practice and low results for childhood immunisations. There were deficiencies in the practice’s vision and values and there was no supporting business plan reflecting and underpinning the vision and values of the practice. Governance arrangements did not operate effectively.

Overall the practice is now rated as good overall.

Our key findings were as follows:

  • The practice had clearly defined and embedded systems and processes to minimise risks to patient safety. This included recruitment, checking of electrical equipment, fire risk assessments and fire safety arrangements.
  • Staff were aware of current evidence based guidance. However, improvements were required in the management of patients with long term conditions.
  • The practice had an induction programme for newly appointed staff and staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Policies and procedures used to govern activity were adapted to the practice.

In addition, at the previous inspection we identified areas where improvements “should” be made. At this inspection we found that all of the improvements had been made. Some of these improvements are described under the key questions we re-inspected. In addition to those we found:

  • A new hearing loop system had been installed to support patients with hearing impairment. Staff had received training on how to use it.

  • Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments. These were cleaned at regular intervals.

  • A carer’s register had been implemented and was reviewed regularly.

However, there were also areas of practice where the provider should make improvements.

The provider should:

  • Continue to review processes and procedures for monitoring and managing patients with long term conditions and levels of exception reporting and take all necessary steps to improve outcomes for patients.

  • Consider providing a practice website.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

8 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs SS & MM Baig on 8 March 2016. Overall the practice is rated as requires improvement.

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

  • Patients were at risk of harm because systems and processes were not implemented in a way to keep them safe. This included recruitment, checking of electrical equipment, fire risk assessments and fire safety arrangements.
  • Although some audits had been carried out, they were not two cycle completed audits and so the practice could not demonstrate that audits were driving improvements to patient outcomes.
  • The practice did not have a formal induction programme for newly appointed staff and could not adequately demonstrate how new members of staff were familiarised with practice policies and procedures.
  • Some policies and procedures used to govern activity were generic and had not been customised to the practice’s needs.
  • There were gaps in staff training including infection control and information governance.
  • The majority of patients said they were treated with compassion, dignity and respect. However, not all consulting rooms had privacy curtains and some patients had concerns about privacy at reception.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses, for instance when temperature readings for the fridge used to store vaccines were outside of the normal range.
  • The practice’s uptake for the breast cancer, bowel cancer and cervical screening programmes were above local and national averages.
  • Patients could book appointments and request repeat prescriptions online.

The areas where the provider must make improvements are:

  • Ensure electrical appliance safety checks are undertaken.
  • Undertake actions to mitigate the risks associated with fire, including ensuring the fire alarm system is fully operational, fire extinguishers are serviced at suitable intervals and regular fire evacuation drills are carried out.
  • Put in place an infection prevention and control protocol and ensure that all staff are provided with infection prevention and control training.
  • Implement a programme of quality improvement initiatives to improve patient outcomes.
  • Ensure that staff have access to practice specific policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
  • Put systems in place to ensure the practice identifies mandatory training requirements for staff and ensures that suitable training is delivered.
  • Ensure recruitment arrangements include all necessary employment checks for staff, for example proof of identity and references.

In addition the provider should:

  • Ensure there is an effective system to track blank prescriptions through the practice in line with national guidance.
  • Ensure there is an effective system for checking emergency medical equipment is fit for use including regular checks of the defibrillator.
  • Consider how to best ensure all staff receive appropriate induction to the practice.
  • Review arrangements for supporting people with hearing impairments.
  • Ensure that planned arrangements to maintain patients’ privacy and dignity during examinations, investigations and treatments in all consulting rooms are carried out.
  • Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Review current arrangements for staff engagement.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

12 September 2013

During a routine inspection

We spoke with people visiting the surgery on the day of our inspection. Most people told us they were happy with the service provided by the medical staff at the practice. One person said 'they're brilliant, lovely doctors, the nurse is very nice'. Another said 'the staff are very nice'. People told us the GPs were approachable, listened, and they could ask questions if they needed to.

Most people we spoke with on the day of our inspection told us they had been able to make an appointment which suited them. However, one person said 'it's difficult to get emergency appointments on the day'. People we spoke with had positive views about the reception staff at the practice. One person said 'the receptionists fit you in for appointments, they're really nice'. All those we spoke with said that their privacy and dignity were respected.

People's care was planned and delivered in a way that met their individual needs. We looked at five people's records regarding chronic disease planning, care and advice. There was evidence that plans were discussed with patients and appropriate referrals made.

We found that people were protected from the risk of abuse because the provider had some procedures in place for safeguarding vulnerable adults and children. Medical staff we spoke with were aware of these procedures. The provider had adequate systems in place to prevent, detect and control the spread of infection. There was also an adequate system for dealing with complaints made by people who used the service.