Archived: East Ham Memorial Hospital

We carried out an announced comprehensive inspection of East Ham Memorial Hospital (also known as Dr Krishnamurthy's Practice) on 7 November 2019 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 12 April 2019. At the last inspection in April 2019 we rated the practice as inadequate overall and the practice was placed into special measures.

We based our judgement of the quality of care at this service 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 rated the practice as inadequate for providing safe services because:

• There were gaps in recruitment and induction checks, including in relation to Disclosure and Barring Service (DBS) checks, references, checks of professional registration, and immunity status.
• The health and safety risk assessment was not practice-specific and a fire risk assessment was overdue.
• There were gaps in staff training, including for fire safety, safeguarding, basic life support and infection control.
• There was inconsistent recording in nurse consultations of whether chaperones had been offered, accepted or declined.
• One of the clinicians was not able to demonstrate how to assemble or use a piece of emergency equipment.
• Staff did not have the appropriate authorisations to administer medicines.

We rated the practice as inadequate for providing well-led services because:

• Staff reported that leaders were approachable, however there were weaknesses in leaders’ capacity to deliver high quality sustainable care.
• There were weaknesses in the overall governance arrangements, for example in relation to oversight of recruitment checks and staff appraisals, monitoring of staff training, and authorisation of medicines.
• Some of the practice’s policies had not been updated in line with specified timeframes or did not contain all the necessary information.
• The systems for managing risks were not effective, as some risks has not been identified or dealt with, including breaches of regulations identified at the previous CQC inspection which had not been addressed.

We rated the practice as requires improvement for providing effective services because:

• We found examples in nurse consultations where consent had not been recorded.
• We identified gaps in staff training and the induction process, and therefore the practice was not able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles effectively.
• The practice’s clinical performance data was generally above or in line with national averages.
• The practice had also carried out clinical audits and non-clinical quality improvement projects.

These areas affected all population groups, so we rated all population groups as requires improvement for providing effective services.

We rated the practice as good for providing caring services because:

• Staff treated patients with kindness, respect and compassion.
• Feedback from patients was positive about the way staff treated people.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected patients’ privacy and dignity.

We rated the practice as good for providing responsive services because:

• The practice organised and delivered services to meet patients’ needs.
• Patients had timely access to the service.
• Complaints were listened and responded to and used to improve the quality of care.

These areas affected all population groups, so we rated all population groups as good for providing responsive services.

The areas where the provider must make improvements are:

• Ensure 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 persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Improve the arrangements for monitoring the work of the nurses through documented reviews of their consultations.
• Improve the system for recording safety alerts to make it easier to monitor and evidence the action taken by the practice.
• Review where adrenaline is stored when vaccines are being administered to ensure it is easily accessible and clarify the dosage instructions for different age groups.
• Ensure that Control of Substances Hazardous to Health (COSHH) risk assessments are completed accurately.
• Improve how carers are identified to ensure information, advice and support is made available to them.

Due to the overall rating of inadequate, this practice will remain 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 table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at East Ham Memorial Hospital (this is a GP Practice also known as Dr Krishnamurthy’s Practice) on 12 April 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service 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 rated the practice as inadequate for providing safe services because:

• There was no system to ensure patients that needed a prescription would be reminded to collect it which had presented a high risk to several patients.
• Several systems and processes to keep people safe and safeguarded from abuse were ineffective, including managing health and safety risks, responding to safety alerts and chaperoning.
• The practice did not have appropriate systems in place for the safe management of medicines.
• Emergency medicines and equipment were not sufficiently accessible or confirmed as fit for use in the event of a medical emergency.
• There were unidentified and unmanaged risks including fire safety, to ensure fit and proper persons were employed, and a lack of fail safes for cervical screening.

We rated the practice as Requires improvement for providing effective services because:

• Patients generally received high quality clinical care but there was limited quality improvement activity.
• Practice nursing staff did not consistently obtain consent to care and treatment when required.
• The practice was not able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
• Clinical performance data was generally above or comparable to local and national averages.
• Staff worked together and with other organisations to deliver effective care and treatment and were proactive in helping patients to live healthier lives.

These areas affected all population groups so we rated all population groups as Requires improvement.

We rated the practice as Good for providing caring services because:

• Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected patients’ privacy and dignity.

We rated the practice as Good for providing responsive services because:

• The practice organised and delivered services to meet patients’ needs.
• Patients had timely access to the service.
• Complaints were listened and responded to and used to improve the quality of care.

These areas affected all population groups so we rated all population groups as Good.

We rated the practice as Inadequate for providing well-led services because:

• The practice had a clear vision, but that vision was not supported by a credible strategy.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• Managers could not show that they had the capacity and skills to deliver high quality, sustainable non-clinical aspects of care.
• Staff were happy at work, but the practice culture lacked leadership oversight and intervention to effectively support high quality sustainable care.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

• Review and improve on site welfare facilities for staff.
• Review and improve arrangements to dispose of clutter around the practice and maintaining hand hygiene equipment.
• Review and improve ways to ensure patients privacy at the reception desk.
• Review the arrangements for childhood immunisation rates to ensure indicative improvements are embedded.

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 act 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.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care