Archived: The Clarence Medical Centre

Updated 3 December 2015

Clarence Medical Centre provides GP primary care services to approximately 1200 people living in Kilburn in the London Borough of Brent. The practice is staffed by two GPs, both male, one nurse, a practice manager and two administrative staff. The practice held a General Medical Services (GMS) contract and was commissioned by NHSE London. The practice was registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder and injury and maternity and midwifery services.

The practice opening hours were 8.30am to 8pm Mondays and 8.30am to 6.30pm Tuesday to Friday. The out of hours services were provided by an alternative provider. The details of the ‘out of hours’ service were communicated in a recorded message accessed by calling the practice when it was closed and details could also be found on the practice website. The practice provided health promotion services including a flu vaccination programme and cervical screening.

The national census data stated 18% of the borough's population was white British, 18% white non-British (among which are large, Polish and Irish communities), 8% black Caribbean, 8% black African (amongst which are a large Somalian community) with various other ethnicities (including Indian, Pakistani, Chinese and Sri Lankan) making up the remaining 48 percent. Around 62% of children under 16 in Brent were classified as living in poverty in 2011, higher than the overall percentage for London (27%) and England (21%). The practice’s catchment area of Kilburn has five small areas which fall into the 20% most deprived nationally.

Updated 3 December 2015

Letter from the Chief Inspector of General Practice

CQC inspected the practice on 4 November 2014. We found some areas of concern and had asked the provider to make improvements.

We undertook this announced comprehensive inspection on 9 September 2015 of Clarence Medical Centre, to check whether there had been any improvements and found that whilst some of our concerns had been addressed we found overall the practice had not improved and we identified further concerns.

Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was no clear infection control lead and the practice had not undertaken an infection control audits since January 2014.
• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, QOF data for this practice showed that overall it was performing below national standards and we did not see any evidence that the practice had any systems to monitor outcomes for patients
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• Urgent appointments were usually available on the day they were requested. However patients said sometimes it was very difficult to get through to the practice when phoning to make an appointment.
• The practice had no clear leadership structure and limited formal governance arrangements.

The areas where the provider must make improvements are

• Ensure clear systems are in place for reporting and recording significant events.
• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision as we found there was an unguarded electric halogen heater in the nurse’s room which presented a serious risk to patients, especially children.
• Take action to address identified concerns with infection prevention and control practice as we found there was no clear infection control lead and no audits had been undertaken since January 2014
• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines as we found the GPs were unfamiliar with the dangers of prescribing high risk medication.
• Ensure there are formal arrangements in place for reviewing patients with long term conditions
• Ensure clinical audits are undertaken in the practice, including completed clinical audit or quality improvement cycles.
• Ensure the GPs understand the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.

Action the provider SHOULD take to improve:

• Clarify who the safeguarding lead for the practice is and ensure all staff are aware of it.
• Develop cleaning records or schedules for the practice.

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 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 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 by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 3 December 2015

The practice is rated as inadequate for the care of people with long term conditions.

We found there were no systems in place to review patients with long term conditions. The GPs told us they would review these patients opportunistically when they attended the practice

The practice kept a register of these patients and longer appointments were available when needed. Very few of these patients had a named GP and personalised care plan. Structured annual reviews were not undertaken to check that patients’ health and care needs were being met. The practice did not run any specific clinics for patients with these conditions and data we reviewed prior to our inspection showed the practice were not performing well in relation to the care and management of patients with diabetes. The GP told us they would give opportunistic diabetic care to patients in this group when they attended the surgery.

Updated 3 December 2015

The practice is rated as inadequate for the care of families, children and young people. There were no systems to identify and follow up patients in this group who were living in disadvantaged circumstances and who were at risk. The practice did not carry out child immunisations at the practice, patients were sent to the local health centre. The practice did not have any effective processes in place to monitor take up of childhood vaccinations. The system in place relied on parents bringing the red book for admin staff to update the records. However, practice staff had completed child protection training

Updated 3 December 2015

The practice is rated as rated as inadequate for the care of older people.

The practice had a list of older people who were housebound whom they would visit regularly. However, although patients over 75 years had a named GP they did not have a register for older people who have complex needs or required additional support. Longer appointments were available for older people when needed, and this was acknowledged positively in feedback from patients. Nationally reported data showed that outcomes for patients for conditions commonly found in older people were mixed, for example dementia diagnosis was 100% whilst flu vaccinations for over 65s was 45%.

Updated 3 December 2015

The practice is rated as inadequate for the care of working-age people (including those recently retired and students). The practice offered extended opening hours for appointments from Monday to Friday, patients could book appointments online. Health promotion advice was offered and limited accessible health promotion material available through the practice. The practice invited patients over 40 years of age to have an NHS health check but we were told the uptake was relatively low.

Updated 3 December 2015

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia). They had a register for patients experiencing poor mental health and had scored 100% in their QOF results for dementia. It had not worked with multi-disciplinary teams in the case management of people experiencing poor mental health. Further, they did not have a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. There was no evidence to confirm that people with poor mental health were called for annual physical health checks.

Updated 3 December 2015

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable. The practice did not hold a register of vulnerable patients except patients with a learning disability. It had carried out some annual health checks for people with a learning disability, but there was no evidence that these were structured or had been followed up.

The practice had not worked with multi-disciplinary teams in the case management of vulnerable people. Most staff knew how to recognise signs of abuse in vulnerable adults and children and were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.