Archived: Dr Rashid Kadhim

Updated 30 March 2017

Dr Kadhim’s practice provides services to approximately 3100 patients in south east London under a Personal Medical Services contract (an agreement between NHS England and general practices for delivering personal medical services). It sits within the Southwark Clinical Commissioning Group (CCG) which has 45 member practices serving a registered patient population of approximately 300,000. Dr Kadhim’s practice provides a number of enhanced services including Childhood Vaccination and Immunisation Scheme; Extended Hours Access; Unplanned Admissions and Rotavirus & Shingles Immunisation.

The staff team at the practice consists of one full time male GP, a part time female practice nurse (one day per week), two part time receptionists and a secretary who is also trained as a phlebotomist. There has been an interim practice manager in post since the inspection in May 2016. A locum female GP provides two sessions per week for patients who wish to see a female doctor, and a salaried female GP has just commenced working at the practice for two sessions per week. The lead doctor provided nine sessions per week, plus two extended hour sessions. The service is provided from this location only, and is located in a purpose built property. The premises are accessible for patients with mobility difficulties with consulting rooms on the ground floor of the two storey building. We noted that there was no external signage to indicate that this was a GP practice.

The practice is open between 8.00am and 6.30pm Monday, Thursday and Friday, and between 8.00am and 7.30pm on Tuesdays and Wednesdays. Appointments are available between 9.15am – 1pm and 3pm – 6.30pm on Mondays, Thursdays and Fridays; and between 9.15am – 1pm and 3pm – 7.30pm on Tuesdays and Wednesdays. Patients who wish to see a GP outside of these times are referred to an out of hour’s service; however, there was no information on display outside of the practice to inform patients of this. The practice does not provide an online appointment booking system although it is working to resolve this.

The provider is registered with the Care Quality Commission as an individual, to carry on the regulated activities of maternity and midwifery services, treatment of disease, disorder or injury, family planning, surgical procedures, and diagnostic and screening procedures.

The practice has a lower percentage than the national average of people with long standing health conditions (46% compared to a national average of 54%). It has a higher percentage of unemployed people compared to the national average (19% compared to 5.4%). The average male and female life expectancy for the CCG area and the practice is in line with the national average for both males and females.

The population in this CCG area is 54% white British. The second highest ethnic group is black or black British (27%). The practice sits in an area which rates within the second most deprived decile in the country, with a value of 35.8 compared to the CCG average of 29.5 and England average of 21.8 (the lower the number the less deprived the area). The patient population is characterised by a below England average for patients, male and female, over the age of 55; and an above England average for patients aged up to 14; and for male patients between the ages of 25 and 49 and female patients between the ages of 25 and 44.

We previously inspected the practice on 10 May 2016. CQC gave the practice an overall rating of inadequate. In July 2016, CQC placed the practice in ‘special measures’ for a period of six months during which time the provider was expected to make improvements to meet all required regulations.

Special measures is a process designed to ensure a timely and co-ordinated response to practices providing inadequate care. Practices in special measures are offered support from NHS England and the local Clinical Commissioning Group. Practices can choose to get further peer advice and support from the Royal College of General Practitioners. Being placed into special measures means that a practice must improve within the specified period to avoid having its registration cancelled by CQC.

Updated 30 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Rashid Kadhim on 10 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Rashid Kadhim on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 9 January 2017. Overall the practice remains rated as Inadequate.

Our key findings were as follows:

• A programme of continuous clinical and internal audit to monitor quality and to make improvements had been commenced however audits had not yet been completed therefore it was not possible to determine what, if any, improvements to patient care had occurred as a result.
• The practice was still in the process of developing an overarching governance framework to support the delivery of the strategy and good quality care. We saw that structures and procedures had been put into place; however, there was insufficient evidence to indicate that the improvements made were substantial enough or sustainable.
• The practice did not offer online appointment booking although it was working to resolve this. It did provide electronic repeat prescriptions.
• The practice provided a nurse for just one day each week which impacted on patient access as it limited the day they could attend. The nurse offered appointments up to 5pm on alternate weeks to accommodate working people and school age children. Following the inspection the practice told us that the local extended primary care service also offered weekend nursing appointments which were available to this practice and bookable in advance.  
• Record keeping in general had significantly improved; however, there were still some gaps identified – for example equipment cleaning, staff files and GP call backs to patients.
• The practice had an up to date fire risk assessment and carried out regular fire drills and monthly testing of fire alarms. We noted that the fire risk assessment had highlighted a considerable number of areas of concern. We were told that the practice was taking steps to address these; however, these actions had not been documented.
• Neither the cleaner, who handled clinical waste bags, nor the lead GP had up to date hepatitis B immunisation.
• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes had improved since the inspection in May 2016, but were still 3% below the CCG average and 4% below the England average.
• Childhood immunisation rates for the vaccinations given to two year olds were between 3% and 21% below the 90% national target.
• Almost all of the 46 patient Care Quality Commission comment cards we received were positive about the service experienced; however, some commented on areas they felt needed to be improved. Predominant amongst these comments was the need to reduce the waiting time once patients had arrived for their appointment. This was reiterated by patients we spoke with on the day, who also commented on the need for more clinical staff and the difficulty in getting an appointment with a female doctor.
• Data from the 2016 national GP patient survey published in July 2016 showed patients rated the practice substantially lower than others for some aspects of care including how well the GP listened; how much time they gave them and how well the GP explained tests and treatment. Patients’ satisfaction with how they could access care and treatment were also, in many instances, considerably below local and national averages even though some had improved from the data published in January 2016.
• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. We saw that meetings now took place with other health care professionals on a regular basis.
• There was now a system in place for reporting and recording significant events.
• Lessons were shared to make sure action was taken to improve safety in the practice.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had recently appointed a salaried GP although this had not led to an increase in GP capacity as the number of locum sessions had reduced since our May 2016 inspection.
• Information about how to complain was available. The practice now maintained a complaints log. This had been updated to include three complaints from early 2016, but there had not been any complaints since then so we were unable to assess how well the new system had been embedded.
• Since the last inspection the practice had put a recruitment policy and procedure into place.

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

Importantly, the provider must:

• Ensure there are an adequate number of practice nurse sessions so as to meet patient demand.
• Demonstrate there is an effective quality improvement programme in place, for example two cycle, completed audits.
• Ensure accurate records are maintained in relation to, for example, fire safety, cleaning of clinical equipment, staff records and the action taken in regard to GP call backs to patients.
• Provide patients with access to online booking.
• Monitor the practice performance and its adherence to guidance; and take action on evidence of poor or deteriorating performance, and to improve performance.

In addition the provider should:

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
• Enable staff, where appropriate, to obtain hepatitis B immunisation.
• Revise the chaperone policy, and continue to review the practice’s policies and procedures.
• Ensure that locum GPs are provided with information relevant to working at this practice.
• Continue to review the staffing levels at the practice, particularly with regard to the availability of a practice nurse, so that the needs of the practice patient list can be met.
• Review and implement strategies to improve the practice child immunisation performance.
• Continue to develop a governance framework to enable recent improvements to be sustained.
• Continue to review the outcomes of the national patient survey and implement measures to improve the patient experience.
• Monitor the punctuality of appointments and patient waiting times.
• Monitor that people who express a preference get adequate access to a GP of the gender of their preference.
• Consider developing a practice website and a practice leaflet.

This service was placed in special measures in July 2016. Insufficient improvements have been made such that there remains a rating of inadequate for caring, responsive and well led. The service will therefore remain in special measures and kept under review. 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.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months), was 5 mmol/l or less (01/04/2015 to 31/03/2016) was 80%, the same as the national average.
• The percentage of patients with asthma, on the register, who had had an asthma review in the preceding 12 months that included an assessment of asthma control using the 3 RCP questions (01/04/2015 to 31/03/2016) was 84% compared to the CCG and national average of 75%.
• The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c was 64mmol/mol or less in the preceding 12 months (01/04/2015 to 31/03/2016) was 74% compared to 78% nationally.

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• Childhood immunisation rates for the vaccinations given were below standard with regard to the percentage of children aged 2 with pneumococcal conjugate booster vaccine; the percentage of children aged 2 with haemophilus influenzae type b and meningitis C booster vaccine; the percentage of children aged 1 with full course of recommended vaccines and the percentage of children aged 2 with measles, mumps and rubella vaccine. The practice offered a walk in baby clinic.
• Children were prioritised for appointments, and appointments were available outside of school hours.
• The practice’s uptake for the cervical screening programme was 76%, comparable to the CCG average of 77% and the national average of 81%.

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice had developed closer working links with the community matrons and district nurses to enable more proactive intervention.

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• The practice did not provide an online appointment booking system although they were working to resolve this.
• Appointments could be booked in advance and there were extended opening hours for patients who worked or students.
• Telephone consultations were available.
• Healthy lifestyle was promoted and patients were referred to services to help them achieve this.
• NHS health checks were promoted.

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• Information on mental health services was displayed in the waiting area.

• All staff had undergone training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
• Performance for mental health related indicators was comparable to national averages. For example the number of patients diagnosed with dementia whose care had been reviewed in a face-to-face review in the preceding 12 months (01/04/2015 to 31/03/2016) was 83% compared to the national average of 84%.

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months (01/04/2015 to 31/03/2016) was 82% compared to the national average of 89%.

Updated 30 March 2017

The practice is rated as inadequate for providing caring, responsive and well led care; and requires improvement for providing safe and effective care. The concerns which led to this rating apply to everyone using the practice, including this population group.

• The practice now attended regular meetings with multi-disciplinary teams in the case management of vulnerable people.
• Staff knew how to recognise signs of abuse in vulnerable adults and children, and were aware of how to contact relevant agencies outside of the practice.
• The practice identified carers on the electronic records system and signposted carers to local support groups and other relevant agencies. The proportion of carers identified by the practice was, however, still low compared to the patient list size.