Archived: Five Elms Medical Practice

Updated 25 August 2016

Five Elms Medical Practice is a single location practice providing GP primary care services to approximately 4,300 people living in the Dagenham neighbourhood of the London Borough of Barking and Dagenham. The practice is in an area that is in the second most deprived decile. The proportion of patients on the register aged 65 or over is significantly higher than the CCG average. Data from Public Health England shows that 17% of the practice population falls into this age group compared to the CCG average of 9%.

The practice is located in a purpose built health centre which is shared with a dental practice and a team of health visitors. The practice shares reception and waiting areas with these services.

There is one full time GP and one long term part-time locum GP who provide a combined average of 18 sessions per week. There is one part time nurse (0.5 Full Time Equivalent) and four staff who share reception and administration duties. The practice has not had a practice manager since 2015. An experienced member of the administration staff has recently been undertaking some of the former practice manager’s duties. A healthcare assistant employed by a local hospital is hired on an hourly basis to undertake NHS health checks.

The practice is 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 are 8:30am to 6:30pm Mondays, Tuesdays, Wednesdays and Fridays and Thursdays, 8:30am to 1:30pm. On the first Tuesday of each month, the opening hours are 8:30am to 1:30pm. Surgery times are from 8:30am to 11:30am, Monday to Friday and from 3:30pm to 6:30pm on Mondays, Tuesdays (except for the first Tuesday of each month), Wednesdays and Fridays. There is no surgery on Thursday afternoons or the afternoon of the first Tuesday of each month. Between 8am - 8.30am every weekday and 1:30pm to 6:30pm every Thursday and first Tuesday of every month, telephone calls are answered by a contracted out of hours (OOH) provider.

The practice does not open at weekends, having opted out of providing OOH services. Between 6.30pm and 8.00am and at weekends patients are directed to the OOH provider for Barking & Dagenham CCG. The details of the out of hours service are communicated in a recorded message accessed by calling the practice when it is closed and details can also be found on the practice website.

According to the 2011 national census, Barking and Dagenham is the seventh smallest of London’s 32 boroughs in terms of population. It has the highest population percentage of young people aged between 0 and 19 (32%) and the highest percentage of lone parent households with dependent children in England and Wales. The Borough is ethnically diverse and the practice population reflects this diversity. In the latest census in Barking and Dagenham, 58% gave their ethnicity as white, 20% as Asian, 15% as Black African and 7% as mixed or other ethnicity.

Before we undertake an inspection, we ask providers to submit certain information including, summaries of complaints and serious adverse events, numbers of staff by role as well as details of training and qualifications, recruitment and training policies and evidence of the quality of care for the six population groups we inspect. The practice had not responded to this request.

At the time of our inspection, the practice was incorrectly registered as a partnership and had been so since April 2015 when a GP who had been a partner, left the practice. The practice has made a number of efforts to the cancel the incorrect registration and register as a sole provider but to date has not properly completed the process.

Updated 25 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Five Elms Medical Practice on 5 April 2016. 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, appropriate recruitment checks on staff had not been undertaken prior to their employment and actions to address concerns with infection control practice had not been taken.
• When there were unintended or unexpected safety incidents, reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement. People did not always receive a verbal and written apology .
• Improvements to patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

• Take action to assess the risk of, prevent, detect and control the spread of infections.
• Take action to assess the risks associated with fire.
• Carry out a risk assessment to determine if staff who act as chaperones need a DBS check.
• Ensure there is an effective system in place for the receipt and distribution of safety alerts to all staff.
• Ensure there are processes for identifying where improvements in clinical care can be made and monitored.
• Take effective and sustainable action in response to patient feedback relating to lack access to the service, difficulties obtaining suitable appointments , involvement in decisions about their care and explanations of tests and treatments.
• Ensure that all staff receive training about confidentiality and information governance
• Ensure staff are supported with and receive professional development, supervision, training and appraisal to enable them to undertake their role.
• Provide appropriate training to staff required to carry out chaperone duties.
• Ensure that all staff receive appropriate training on infection prevention and control.
• Ensure recruitment arrangements include all necessary pre-employment checks for all staff.

The areas where the provider should make improvement are:

• Provide staff with appropriate and up to date policies and guidance, which are reflective of the requirements of the practice.
• Review current interpretation services to ensure these are available to patients on request.
• Review arrangements for involving staff in the vision and strategy for the practice and in making improvements in how the practice is run.
• Review the complaints process to ensure it is easily accessible by patients.
• Review arrangements for identifying and supporting 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 25 August 2016

The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led care. The issues identified as inadequate affected all patients including this population group.

• Longer appointments and home visits were available when needed.
• Although all these patients had a named GP, data from the National GP Survey showed that only 5% of patients said they always or almost always saw their preferred GP.

Updated 25 August 2016

The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led care. The issues identified as inadequate affected all patients including this population group.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
• The practice’s uptake for the cervical screening programme was 70%, which was comparable to the CCG average of 72% and the national average of 74%.

Updated 25 August 2016

The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led care. The issues identified as inadequate affected all patients including this population group.

• Although patients aged over 75 were provided with a telephone number which bypassed the main switchboard, data from the National GP Survey showed that only 17% of patients found it easy to get through to the surgery on the telephone (national average 73%).
• The practice had engaged with the Everyone Counts scheme, one part of which aims to improve health outcomes for patients aged over 75.

Updated 25 August 2016

The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led care. The issues identified as inadequate affected all patients including this population group.

• Telephone appointments were available for patients who were unable to attend in person or who were unsure if their condition required attention.
• Health checks were available for new patients and those aged over 40 but this was not actively promoted
• The practice did not offer any extended opening hours to support those who worked or had other commitments during the day.

Updated 25 August 2016

The provider was rated as inadequate for safe, effective, caring, responsive and well-led. The issues identified as inadequate affected all patients including this population group.

• It had not worked with multi-disciplinary teams in the case management of people experiencing poor mental health.
• Performance data for patients experiencing mental health indicated that most patients had received an annual review but individual care plans were not always produced. For instance, data showed that 97% of patients with schizophrenia, bipolar affective disorder and other psychoses had their smoking status recorded (national average 94%) but only 65% had an agreed care plan.
• Performance data indicated that only 25% of patients diagnosed with dementia had care plans in place. We saw that some patient records had been coded incorrectly in this regard and that care plans were in place for patients diagnosed with dementia but the practice was unable to provide data to challenge published performance data.
• The practice had not told patients experiencing poor mental health about support groups or voluntary organisations.
• It 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.

Updated 25 August 2016

The provider was rated as inadequate for providing safe, effective, caring, responsive and well-led care. The issues identified as inadequate affected all patients including this population group.

• The practice offered longer appointments for patients with a learning disability.
• There was no access to interpreting services for patients who needed this.
• The practice held a carers register but there were no specific arrangements to support this group of patients and there was no evidence the practice were proactively trying to identify carers.
• The practice worked with multi-disciplinary teams in the case management of vulnerable people but this was generally informal and record keeping was limited.