We carried out an announced comprehensive inspection at The Avicenna Medical Practice on 24 October 2018 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a second CQC inspector and a GP specialist advisor. The practice was previously inspected on 18 November 2014 and was rated as good.
Our judgement of the quality of care at this service is based 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 found that:
•People were not adequately protected from avoidable harm and abuse.
•The delivery of high quality care was not assured by the leadership, governance and culture of the practice.
•Some legal requirements were not met.
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. We saw that numerous members of the clinical team including advanced practitioners and nursing staff had not attended any child safeguarding training. For those staff that that had completed safeguarding training, the provider could not evidence that they were trained to the required level. Several key staff members of staff had not attended adult safeguarding training.
•The provider did not have an effective system in place for the documentation, discussion, review and management of significant events. The provider could not evidence that reflections or learning from incidents or changes to policies or procedures were disseminated and discussed with staff team.
We rated the practice as inadequate for providing effective services because:
•There was limited monitoring of the outcomes of care and treatment.
•The provider was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
•The provider did not carry out any quality improvement activity.
•There were significant gaps in staff mandatory training which did not align with policy requirements at the practice. A number of staff were not trained in equality and diversity, infection prevention and control, fire training, health and safety, sepsis and learning disability awareness.
We rated the practice as inadequate for providing caring services because:
•The practice did not respond in a meaningful way to patient feedback.
•National GP patient survey data showed that patient satisfaction in relation to feeling cared for were below CCG and national averages.
We rated the practice as inadequate for providing responsive services because:
•National GP patient survey data, 2018 showed that patients were not able to access services in a timely manner. Patients told us on the day of inspection that they experienced difficulty getting an appointment.
•The practice could not demonstrate they had responded to the National GP patient survey 2018 results, despite responses to the survey being significantly below national averages.
•The systems and processes for receiving and acting on complaints were not operating effectively. The practice did not document verbal complaints and therefore could not evidence that all complaints to the practice were documented and responded to appropriately. Complaints were not reviewed and discussed with the staff team. The practice could not demonstrate that complaints were responded to in accordance with the NHS complaints procedure or that changes were made as a result.
We rated the practice as inadequate for providing well-led services because:
•The overall governance arrangements were ineffective. Systems and processes were not established or operated effectively to ensure good governance.
•A number of policies and procedures at the practice were not appropriately reviewed, dated or contained up to date or practical information. We saw that some policies contained conflicting or misleading information.
•The practice did not have a fully functioning and embedded system in place to safely manage the appropriate use, distribution and storage of prescription stationery in line with NHS Protect guidance.
•The practice did not conduct clinical audits or quality improvement activity.
•On the day of inspection, we saw evidence of one clinical meeting, one multi-disciplinary team meeting and two nurse meetings in 2018. We were not assured regular clinical meetings took place. Meetings minutes were unstructured and we saw that issues such as safeguarding, complaints and significant events were not discussed with the staff team.
The areas where the provider must make improvements are:
•Ensure that 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.
•Ensure that persons employed by the service are suitably trained as is necessary to enable them to carry out the duties they are required to perform.
The areas where the provider should make improvements are:
•Review and improve the approach to the management of test results and implement a clinically led protocol to guide staff to which results or correspondence require a clinical over view.
•Review, improve and encourage the uptake of screening by patients registered with the practice, including cervical, breast and bowel screening.
After the inspection on the 24 October 2018, we wrote a formal letter to the provider. This involved an incident which was being handled by the provider as a complaint. We requested the provider forward a copy of any investigation, findings or applied learning which may occur as a result of a further review of this incident.
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 tables.
Professor Steve Field CBE FRCP FFPH FRCGP