Archived: Dr George & Partner

Updated 5 January 2017

Dr George and Partner are located in a purpose built medical centre in a residential area of Westcliff on Sea, Essex. The practice provides services for 5000 patients.

The practice has a branch surgery (Thorpe Surgery) which is located at Thorpe Surgery, 38 Acacia Drive, Thorpe Bay Essex. We did not visit the branch surgery as part of this inspection. The practice holds a General Medical Services (GMS) contract and provides GP services commissioned by NHS England and Southend Clinical Commissioning Group. A GMS contract is one between GPs and NHS England and the practice where elements of the contract such as opening times are standardised.

The practice population is lower than the national average for younger people and children under 18 years. The practice population is significantly (more than double the national percentage) for older people aged 65 years and over.

Economic deprivation levels affecting children, older people are higher than the practice average across England. Life expectancy for men and women is slightly lower than both the local CCG and national averages. The practice patient list is higher than the national average for long standing health conditions. It has a lower than the national average for working aged people in employment or full time education and similar numbers of working age people that are unemployed.

The practice is managed by two GP partners who hold joint financial and managerial responsibility. One of the GP partners is the Registered Manager. A Registered Manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

The practice employs two locum GPs. In total three male GPs and one female GP work at the practice. The practice also employs one practice nurse, a practice manager and a team of receptionists and administrators.

The practice provides the following directed enhanced services:

• Minor surgical procedures.

• Extended opening hours.
• Childhood immunisations and vaccinations.
• Learning disabilities.
• Flu vaccinations.

The practice is open from 8.30am to 6.30pm on weekdays with late evening opening up to 8pm on Tuesdays or Wednesdays. Morning appointments are available between 8.40am and 11.10am on Mondays, Tuesdays, Wednesdays and Fridays, and between 9.30am and 12pm on Thursdays. Afternoon appointments are available 2pm and 4pm on Wednesdays.

Evening appointments are available between 4.30pm and 6pm on Mondays, Tuesdays, Wednesdays and Fridays and between 4.15pm and 5.45pm on Thursdays. Late evening appointments are available up to 7.50pm on Tuesdays or Wednesdays.

The practice has opted out of providing GP out of hour’s services. Unscheduled out-of-hours care is provided by IC24 and patients who contact the surgery outside of opening hours are provided with information on how to contact the service.

Updated 5 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr George and Partner on 19 April 2016. Overall the practice is rated as inadequate. The practice is rated as inadequate for safe, effective and well led domains. It is rated as requires improvement for responsive and caring domains.

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

• There was a an overall lack of clear leadership within the practice and little oversight and governance for recognising and addressing issues in relation to safety and quality improvement
• Published information in relation to safety such as safety alerts was not widely shared with staff or acted on to help minimise risks to patients.
• Learning from when things went wrong was not embedded into practice and reviewed to help minimise recurrences.
• Repeat prescriptions were routinely issued by reception staff without the appropriate medicines reviews having been carried out.
• GPs had access to relevant guidance in relation to assessing, treating and monitoring patients. However this was not followed consistently. Medicine and health reviews for patients with long term conditions, older patients, patients suffering from poor mental health and vulnerable patients were not carried out in line with guidance.
• Some staff had not received training in safeguarding adults and children and for the role of chaperone. There were insufficient numbers of staff working at the practice to meet the needs of patients.
• Appropriate checks such as Disclosure and Barring Disclosure (DBS) checks were not carried out for relevant staff, including staff who carried out chaperone duties and there were no risk assessments in place to determine that these checks were not needed.
• There were limited systems for assessing some risks including those associated with medicines. Fridge temperatures were not monitored properly to ensure that temperature sensitive medicines such as vaccines were stored properly.
• There were procedures in place to ensure that equipment was tested and calibrated where necessary to ensure that it worked properly.
• There were arrangements in place to minimise the risk of fire. The practice had appropriate equipment, which was tested regularly. Fire exits were clearly signposted. However staff had not undergone fire safety training since 2013.
• There were procedures in place to minimise the risk of infection. However these were not adhered to consistently. The practice was visibly clean and infection control audits were carried out. However staff did not have infection control training and the practice could not demonstrate that relevant staff had been vaccinated / had immunity to Hepatitis B.
• There was no business continuity plan to deal with untoward incidents that may affect the day to day running of the practice.
• The practice did not have a complete supply of recommended emergency medicines and did not stock oxygen for use in the event of a medical emergency.
• The risks of legionella had been assessed.
• Staff were not recruited robustly with all of the appropriate checks carried out to determine each person’s suitability and fitness to work at the practice.
• There were procedures in place for obtaining patients consent to care and treatment however consent was not routinely recorded and the GPs were unable to demonstrate that patients had been told about the intended benefits or potential risks of treatments such as joint injections.
• There was a lack of clinical audits, reviews or other quality improvement in place at the practice to monitor and improve patient care and treatment.
• The majority of staff had not undertaken training in areas including fire safety, safeguarding, chaperone duties, basic life support and infection control. Staff had not undertaken training in basic life support since 2011.
• There was a system for staff appraisal. However the practice manager had never had an appraisal. There were no procedures in place for dealing with underperformance or alleged misconduct of staff including GPs.
• Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment. They said that staff were helpful, polite and courteous.
• Data from the most recent GP patient survey showed that the practice performed similarly to or better than the local and national averages for helpfulness of reception staff and the nurse; and lower for some aspects of care including GPs treating patients with care and concern, giving them enough time and listening to them.
• Information about services and how to complain was available and easy to understand. Complaints were investigated and responded to promptly and apologies given to patients when things went wrong or their experienced poor care or services.
• The practice offered a range of appointments including face to face, telephone and online consultations. Data from the most recent GP patient survey showed that the practice performed better than the local and national averages for patient satisfaction in relation to access to appointments and opening times. This was also supported by comments made by patients who we spoke with and those who completed comment cards.
• The practice was located in purpose built premises with disabled access toilets and baby changing facilities.
• The practice could not demonstrate that they proactively sought feedback from staff and patients. Where patients made comments or suggestions or raised complaints these were acted on.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure that safety is monitored and risks to patients and staff are assessed and managed, including acting on safety information such as safety alerts to help reduce the risks of unsafe care and treatment, learning from significant events and when things go wrong and embedding this into staff practices. This includes identifying and managing risks to patients such as the risks associated with medicines, the issuing of prescriptions, carrying out appropriate patient reviews, infection control and dealing with emergency situations including medical emergencies.

• Ensure that staff are recruited robustly with all of the appropriate checks carried out in relation to their suitability and skills to carry out their roles.

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

• Ensure that there are sufficient numbers of suitably trained staff to meet the needs of patients.
• Ensure that systems are in place for monitoring and improvement of the service quality through reviews, clinical and non-clinical audit or by other means. This also includes improving the leadership and governance arrangements at the practice.

Additionally the provider should:

• Review the arrangements for recording information about patients’ needs and any changes to these so that information is accessible to relevant staff.

• Review the practice performance from national surveys and implement improvements where needed.
• Consider ways in which patients views and suggestions for improvement can be encouraged.
• Review the procedures for obtaining and recording consent so that these demonstrate that patients have been made aware of the intended benefits and potential risks of treatment.
• Ensure that a business continuity plan is in place in the event of circumstances that might disrupt the services to patients.
• Improve the identification of patients who are carers.

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

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, including people with long-term conditions.

• Nationally reported data showed that practice performance for monitoring and treating patients with some long-term conditions was lower than other practices. This included the monitoring of diabetes and chronic obstructive pulmonary disease (COPD).
• We were told that locum GPs focussed mainly on acute care which meant that people with long-term health conditions did not always have their health checks done. This included patients with a terminal illness.
• Medicine reviews including those for patients who were prescribed high risk medicines were not being monitored effectively to ensure their medicines were prescribed at the correct and safe dosage.
• Data from the most recent GP patient survey showed that the practice performed lower than others both locally and nationally for some aspects of care including:
• 78% said the last GP they saw was good at explaining tests and treatments compared to the CCG average of 80% and national average of 86%.
• 70% said the last GP they saw was good at involving them in decisions about their care compared to the CCG average of 76% and the national average of 82%.

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, including families, children and young people.

• The practice offered same day appointments for children.
• Appointments were available outside of school hours.
• Post-natal and baby checks were available to monitor the development of babies and the health of new mothers.
• Immunisation rates were similar to other GP practices for all standard childhood immunisations.
• Age appropriate information was available for young people in relation to sexual health.
• Data from the most recent GP patient survey showed that the practice performed lower than others both locally and nationally for some aspects of care including:
• 78% said the last GP they saw was good at explaining tests and treatments compared to the CCG average of 80% and national average of 86%.
• 70% said the last GP they saw was good at involving them in decisions about their care compared to the CCG average of 76% and the national average of 82%.

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, including older people.

• Older people had a named GP who was responsible for their overall care and treatment. However older people who were at risk of deteriorating health did not have a care plan in place.
• Patients’ health and medicine reviews were not being carried out effectively to ensure that they received safe and appropriate care.
• Same day urgent and pre-booked routine appointments were available and could be booked in person or by telephone and patients told us that they could access appointments easily.
• Longer visits, home visits and telephone consultations were available as needed.
• There were regular meetings with other professionals to identify and meet the needs of older patients.

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, including working-age people (including those recently retired and students).

• The practice offered a full range of health promotion and screening that reflected the needs for this age group including NHS health checks and its performance was similar to other practices for the uptake of these checks.
• Medicines and health reviews were not carried out in line with relevant guidance
• Appointments were flexible and extended opening hours with late evening appointments were available.
• Patients had access to telephone consultations if they could not attend the practice.

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, people experiencing poor mental health (including people with dementia).

• The practice provided dementia screening reviewed and monitored patients with dementia in face-to-face reviews. However these patients did not have care plans in place.
• GPs were unaware of the Mental Capacity Act and their responsibilities in relation to this where patients lacked capacity to make decisions in relation to their care and treatment.
• Data available to us showed that the practice performance for monitoring for people with poor mental health conditions was lower than other GP practices for some aspects.
• 90%of patents with a mental health disorder had a record of their alcohol consumption. This was the same as the national average.
• 53% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan in place, which was significantly lower than the national average of 88%.

Updated 5 January 2017

The provider was rated as inadequate overall and this includes for this population group. The provider was rated as inadequate for safe, effective and well led domains. It was rated requires improvement for caring and responsive. The concerns which led to these ratings apply to everyone using the practice, including people whose circumstances may make them vulnerable.

• The practice had a dedicated safeguarding lead who liaised with local safeguarding teams and needed to help safeguard vulnerable adults and children. However staff were not trained in safeguarding people who may be vulnerable or chaperoning patients.
• GP partners were unaware of the Mental Capacity Act as it related to their responsibilities when treating patients who may not be able to make informed decisions about their care and treatment.
• The practice held a register of patients living in vulnerable circumstances including patients with a learning disability. However these patients did not have care plans in place and patients with learning disabilities did not have regular health checks.
• There were 33 patients with a learning disability on the practice register. We reviewed the records for two of these patients and found that neither patient had a medicines review or health check within the preceding three years.
• The practice identified patients who were carers and provided information about the range of benefits and support that were available to them.
• Data from the most recent GP patient survey showed that the practice performed lower than others both locally and nationally for some aspects of care including:
• 78% said the last GP they saw was good at explaining tests and treatments compared to the CCG average of 80% and national average of 86%.
• 70% said the last GP they saw was good at involving them in decisions about their care compared to the CCG average of 76% and the national average of 82%.